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

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 could no longer be ignored.

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

Impact of Socio-Medical Factors on the

2006).

Prevention and Treatment of HIV/AIDS Among Specific Subpopulations 293

Rudolph et al., 2010(A); Rudolph et al., 2010(B); Santibanez et al., 2006) and is cost effective and does not lead to increase drug injection or recruit first time injectors (Santibanez et al.,

Lack of available substance abuse treatment programs and HAART is yet another factor that explains the impact of injecting drug use on the HIV/AIDS epidemic. Estimates from the 2007 National Survey on Drug Use and Health (NSDUH) indicate that approximately 7.5 million persons needed treatment for an illicit drug problem and of those needing treatment, about 6.2 million persons did not receive substance abuse treatment (Substance Abuse and Mental Health Services Administration, 2008). Injection drug users experience numerous barriers to treatment. However, a substantial portion of IDUs report an inability to access substance abuse treatment, highlighting a structural barrier to care (Milloy et al., 2009). Pollack and D'Aunno report much IDUs addiction treatment is provided through outpatient treatment centers, however few offer the suggested CDC HIV counseling and testing to their clients (2010), and miss opportunities to diagnose HIV. Additional findings indicate that injection drug itself is a major barrier to HAART initiation (Arasteh & Des Jarlais, 2009; Mehta et al., 2010). Many IDUs do not initiate HAART, or initiate HAART after significant delay (Mehta et al., 2010). Moreover injection drug users have been found to received less HAART and derive less benefit from HAART when received (Arasteh & Des Jarlais, 2009). For IDU's in methadone maintenance programs drug interactions often mean modifications to their HAART regiments (Arasteh & Des Jarlais, 2009). Often physicians are reluctant to prescribe HAART therapy to IDUs because of incomplete adherence, and unstable lifestyles that can promote resistance to antiretroviral therapy (Werb et al., 2010; Wolfe et al., 2010). Greater concerns exists for the possibility that drug –resistant HIV strains

Sexual transmission of HIV from IDUs to other persons – both other injectors and non-drug user's injection partners has important public health implications (Arasteh & Des Jarlais, 2009; Des Jarlais & Seman, 2008; Meader et al., 2010; Strathdee & Patterson, 2005; Wolfe et al., 2010). IDUs are considered a bridge to spreading HIV to persons through sexual contact and to HIV-infected children. Mothers who reported injection drug use or who had sex with an injection drug user accounted for 51% of cases of mothers documented with HIV (CDC, 2009). In 2006 the CDC revamped universal guidelines requiring HIV testing of all pregnant women without requiring separate written consent allowing early diagnosis of HIV and decreased risk of perinatal transmission from mother to infant (Gaskins, 2010). Early diagnosis and effective antiretroviral therapy has decreased perinatal transmission rates to less than 2% (Gaskin). Nondisclosure of HIV positive status among IDUs may contribute to sexual spread of HIV from IDUs. Significant disincentives and barriers to revealing a HIV positive status may contribute to nondisclosure. Fear of isolation, abandonment, rejection and criminal prosecution5 may limit disclosure and limit the safety of subsequent sexual activity (Kalichman, 2005). These factors are particularly salient for sex workers infected with HIV. Many IDUs, male and female alike, trade sex for money/or drugs (Friedman et al., 1999). Other factors explaining the impact of injection drug use on sexual transmission highlight that drug use is often concentrated in neighborhoods (Rotheram-Borus et al., 2010), and high rate of injection drug use and risky sexual behavior are often reported among IDUs in low income communities (Wolfe et al., 2010). Des Jarlais & Seman believe

5 As of 1999 31 states had statues making sexual contact without disclosure a criminal offense and many

laws now address exposure (whether or not condoms were involved) not just infection.

could be transmitted to the wider community (Werb et al., 2010).

Fig. 3.1. Schematic history of the New York City HIV epidemic among people who inject drugs. (Source; Freidman et al., 2008)

several factors that explain the nexus between IDUs and the transmission of HIV. The first of these factors includes the sharing of used syringes and drug equipment (works) (Friedman et al., 1999; Rudolph et al., 2010).Drug equipment such as; (1) used bottle caps, spoons, or other containers ("cookers"); (2) used pieces of filtering cotton or cigarette filters ("cottons"); and (3) water that was already used to dissolve drugs or clean syringes (Friedman et al., 1999) allows for the transfer of infected bloodproduct from one person to the next. Subsets of IDU's who share works and injection shooting galleries (Des Jarlais & Seman, 2008) ,where one syringe is often rented to numerous clients, or those that participate in backloading3 or frontloading4 are particularly more likely to become infected (Des Jarlais & Seman, 2008; Friedman, et al., 1999; Santibanez et al., 2006). IDUs often share works due to restricted access to sterile needles and syringes. For example, mechanisms to limit access to clean syringes can be instituted by state laws that require a prescription to obtain syringes, thereby, outlawing syringe exchange programs (SEPS) in some states. Additionally, law enforcement strategies such as placing police near needle exchange sites and arresting IDUs for drug residue in a used syringe can encourage needle sharing (Des Jarlais & Seman, 2008). However, research indicates that increased access to SEPs exchange has lowered syringe sharing among IDUs, thereby lowering levels of infection among individuals and the larger community, (Riley, et al., 2010; Rotherman-Borus et al., 2010;

<sup>3</sup> Backloading refers to the practice of splitting /sharing drugs, whereby solution of dissolved drugs (and perhaps HIV) is squirted from one person's syringe to another using the back or plunger end of the receiving syringe.

<sup>4</sup> Frontloading refers to the practice of splitting /sharing drugs, whereby solution of dissolved drugs (and perhaps HIV) is squirted from one person's syringe to another. In frontloading, the needle is removed and the drug is transferred through the front of the syringe. Frontloading is less common in the United States because the diabetic syringes commonly used in the US do not have detachable needles.

Fig. 3.1. Schematic history of the New York City HIV epidemic among people who inject

several factors that explain the nexus between IDUs and the transmission of HIV. The first of these factors includes the sharing of used syringes and drug equipment (works) (Friedman et al., 1999; Rudolph et al., 2010).Drug equipment such as; (1) used bottle caps, spoons, or other containers ("cookers"); (2) used pieces of filtering cotton or cigarette filters ("cottons"); and (3) water that was already used to dissolve drugs or clean syringes (Friedman et al., 1999) allows for the transfer of infected bloodproduct from one person to the next. Subsets of IDU's who share works and injection shooting galleries (Des Jarlais & Seman, 2008) ,where one syringe is often rented to numerous clients, or those that participate in backloading3 or frontloading4 are particularly more likely to become infected (Des Jarlais & Seman, 2008; Friedman, et al., 1999; Santibanez et al., 2006). IDUs often share works due to restricted access to sterile needles and syringes. For example, mechanisms to limit access to clean syringes can be instituted by state laws that require a prescription to obtain syringes, thereby, outlawing syringe exchange programs (SEPS) in some states. Additionally, law enforcement strategies such as placing police near needle exchange sites and arresting IDUs for drug residue in a used syringe can encourage needle sharing (Des Jarlais & Seman, 2008). However, research indicates that increased access to SEPs exchange has lowered syringe sharing among IDUs, thereby lowering levels of infection among individuals and the larger community, (Riley, et al., 2010; Rotherman-Borus et al., 2010;

3 Backloading refers to the practice of splitting /sharing drugs, whereby solution of dissolved drugs (and perhaps HIV) is squirted from one person's syringe to another using the back or plunger end of

4 Frontloading refers to the practice of splitting /sharing drugs, whereby solution of dissolved drugs (and perhaps HIV) is squirted from one person's syringe to another. In frontloading, the needle is removed and the drug is transferred through the front of the syringe. Frontloading is less common in the United States because the diabetic syringes commonly used in the US do not have detachable

drugs. (Source; Freidman et al., 2008)

needles.

the receiving syringe.

Rudolph et al., 2010(A); Rudolph et al., 2010(B); Santibanez et al., 2006) and is cost effective and does not lead to increase drug injection or recruit first time injectors (Santibanez et al., 2006).

Lack of available substance abuse treatment programs and HAART is yet another factor that explains the impact of injecting drug use on the HIV/AIDS epidemic. Estimates from the 2007 National Survey on Drug Use and Health (NSDUH) indicate that approximately 7.5 million persons needed treatment for an illicit drug problem and of those needing treatment, about 6.2 million persons did not receive substance abuse treatment (Substance Abuse and Mental Health Services Administration, 2008). Injection drug users experience numerous barriers to treatment. However, a substantial portion of IDUs report an inability to access substance abuse treatment, highlighting a structural barrier to care (Milloy et al., 2009). Pollack and D'Aunno report much IDUs addiction treatment is provided through outpatient treatment centers, however few offer the suggested CDC HIV counseling and testing to their clients (2010), and miss opportunities to diagnose HIV. Additional findings indicate that injection drug itself is a major barrier to HAART initiation (Arasteh & Des Jarlais, 2009; Mehta et al., 2010). Many IDUs do not initiate HAART, or initiate HAART after significant delay (Mehta et al., 2010). Moreover injection drug users have been found to received less HAART and derive less benefit from HAART when received (Arasteh & Des Jarlais, 2009). For IDU's in methadone maintenance programs drug interactions often mean modifications to their HAART regiments (Arasteh & Des Jarlais, 2009). Often physicians are reluctant to prescribe HAART therapy to IDUs because of incomplete adherence, and unstable lifestyles that can promote resistance to antiretroviral therapy (Werb et al., 2010; Wolfe et al., 2010). Greater concerns exists for the possibility that drug –resistant HIV strains could be transmitted to the wider community (Werb et al., 2010).

Sexual transmission of HIV from IDUs to other persons – both other injectors and non-drug user's injection partners has important public health implications (Arasteh & Des Jarlais, 2009; Des Jarlais & Seman, 2008; Meader et al., 2010; Strathdee & Patterson, 2005; Wolfe et al., 2010). IDUs are considered a bridge to spreading HIV to persons through sexual contact and to HIV-infected children. Mothers who reported injection drug use or who had sex with an injection drug user accounted for 51% of cases of mothers documented with HIV (CDC, 2009). In 2006 the CDC revamped universal guidelines requiring HIV testing of all pregnant women without requiring separate written consent allowing early diagnosis of HIV and decreased risk of perinatal transmission from mother to infant (Gaskins, 2010). Early diagnosis and effective antiretroviral therapy has decreased perinatal transmission rates to less than 2% (Gaskin). Nondisclosure of HIV positive status among IDUs may contribute to sexual spread of HIV from IDUs. Significant disincentives and barriers to revealing a HIV positive status may contribute to nondisclosure. Fear of isolation, abandonment, rejection and criminal prosecution5 may limit disclosure and limit the safety of subsequent sexual activity (Kalichman, 2005). These factors are particularly salient for sex workers infected with HIV. Many IDUs, male and female alike, trade sex for money/or drugs (Friedman et al., 1999). Other factors explaining the impact of injection drug use on sexual transmission highlight that drug use is often concentrated in neighborhoods (Rotheram-Borus et al., 2010), and high rate of injection drug use and risky sexual behavior are often reported among IDUs in low income communities (Wolfe et al., 2010). Des Jarlais & Seman believe

 5 As of 1999 31 states had statues making sexual contact without disclosure a criminal offense and many laws now address exposure (whether or not condoms were involved) not just infection.

Impact of Socio-Medical Factors on the

2009).

Prevention and Treatment of HIV/AIDS Among Specific Subpopulations 295

are disproportionately women of color; African American and Latino women specifically. While blacks make up only 12% of the U.S. population, they represented nearly half of all people living with HIV in the U.S. in 2006 (46%, or 510,100 total persons). Sixty-four percent of all women living with HIV/AIDS are black. The prevalence rate for black women (1,122 per 100,000) was 18 times the rate for white women (63 per 100,000). Likewise, Hispanics/Latinos account for 15% of the U.S. population, but they accounted for 18% of people living with HIV in 2006 (194,000 total persons). The prevalence rate for Hispanic/Latino women (263 per 100,000) was four times the rate for white women (63 per 100,000) (CDC, 2008; Hall, 2008). An explanation for the disparity in the biological transmission of HIV among women of color is extricable bound to social and economic

Fig. 4.1. Women as a Proportion of New Diagnosis 1985-2005. (Source; Kaiser Foundation) There is little difference in opportunistic processes or disease progression in women and men with HIV/AIDS (Gaskins, 2010). However, while heterosexual transmission of the HIV can occur both from males to females and from females to males (Gaskins, 2010), biologically women are more susceptible to contracting the virus (Fasula et al., 2009; Gaskins, 2010; Johnson & Johnstone, 1993; Minkoff et al.,1995;Nichols et al., 2002; Weeks et al,1996; Zierler & Krieger, 1997). There is increased biological efficiency of HIV transmission from the male to female in heterosexual intercourse (Campbell, 1999; Fasula et al., 2009, Minkoff et al, 1995). The proportion of AIDS cases in women attributed to sex with men rose steadily from 15% in 1983 to 38% in 1995 (Minkoff et al., 1995; Zierler &. Krieger, 1997). Today approximately 75%-85% of new HIV infections in women stem from heterosexual contact (Doherty et al, 2009; Fasula et al., 2009) *(figure 4.2)*. Susceptibility to HIV is further increased with the risk of trauma to cervical cells during intercourse (Gaskins, 2010; Nichols et al., 2002), and the presence of sexually transmitted diseases in women (ex. Human Papamoilla Virus (HPV), gonorrhea, Trichomonas vaginalis, chlamydia etc.) and other gynecologic infections,that can facilitate the acquisition of HIV (Gaskins, 2010: Sutton et al.,

relations of class, gender, race, and sexuality (Zierler & Kreiger, 1997).

that HIV can spread from IDUs to non-injecting sex partners and develop into sustained heterosexual transmission within certain communities (2008). This heterosexual and selfsustained transmission may well explain the high rates of transmission among Black women in the U.S. (*see section 4: Black and Latino women*).

#### **3.1 Interventions**

The primary focus of prevention and intervention programs developed for IDUs have been harm reduction strategies and behavioral interventions. Harm reduction is referred to as a set of policies and programs working collaboratively to reduce drug related harm (Friedman, et al., 2007). Harm reduction is based on a strategy that departs from the criminalization of addiction and rather treats addiction as a chronic medical disease. Two of the most popular harm reduction strategies are sterile needle exchange and acquisition programs and opioid agonist therapy (OAT). While both are controversial, these programs have been associated with reductions in and the cessation of injection drug use (Des Jarlais & Seman, 2008; Riley et al., 2010; Rudolph et al.,2010a; Vlahov et al., 2010). Opioid agonist therapies (OAT) were developed to treat opioid dependence, which can involve long lasting physiological and molecular adaptations in the brain. One of the most widely used forms of OAT is methadone maintenance therapy. Methadone blocks the euphoric effects of other opioids and is associated with decreased illicit drug use (Strathdee & Patterson 2005; Vlahov, et al., 2000). Buprenorphine is another popular OAT used among IDUs who are HIV positive. Buprenorphine is safer for use in HIV infected persons receiving HAART because it has fewer drug interactions (Vlahov et al., 2010). Behavioral interventions focus on encouraging IDUs to refrain from risk behaviors (injection drug use, unprotected sex, and sharing drug paraphernalia) that can promote the spread of HIV. These interventions can reduce risk behaviors of IDUs at the level of the individual or social network (Freidman et al., 1999; Santibanez et al., 2006; Vlahov et al., 2010). Drug abuse treatment is the most widely endorsed intervention to reduce HIV-associated risks behaviors among IDUs (Strathdee & Patterson, 2005).

#### **4. Black and Latino women**

The HIV/AIDS epidemic rapidly spread and impacted women (Zierler & Kreiger, 1997) and urban communities of color during the period when epidemiological, government and media attention was focused almost solely on the gay population and injection drug users (Weeks et al., 1996). In 1981, six women in the United States were presented with an unexplained underlying cellular immune deficiency. These symptoms were similar to the phenomenon experienced by gay males in the United States that later lead to the official recognition of AIDS. Moreover, research indicates that between 1980 and 1981, 48 women died of AIDS related causes of death (Zierler & Kreiger, 1997). The potential magnitude of the female epidemic continued largely unremarked. Although men continue to represent the majority of new HIV cases, thirty years after the recognition of the disease the proportion of women infected with HIV/AIDS continues to rise.In 1985, women represented 8% of AIDS diagnoses; by 2005 they accounted for 27% (*Figure 4.1*) (CDC, 2007). In 1994, HIV/AIDS represented the third leading cause of death among women (Saul et al., 2000; Weeks et al., 1996;). The route of transmission for an overwhelming majority of new HIV cases among women is through heterosexual contact. The majority of the women infected with the virus

that HIV can spread from IDUs to non-injecting sex partners and develop into sustained heterosexual transmission within certain communities (2008). This heterosexual and selfsustained transmission may well explain the high rates of transmission among Black women

The primary focus of prevention and intervention programs developed for IDUs have been harm reduction strategies and behavioral interventions. Harm reduction is referred to as a set of policies and programs working collaboratively to reduce drug related harm (Friedman, et al., 2007). Harm reduction is based on a strategy that departs from the criminalization of addiction and rather treats addiction as a chronic medical disease. Two of the most popular harm reduction strategies are sterile needle exchange and acquisition programs and opioid agonist therapy (OAT). While both are controversial, these programs have been associated with reductions in and the cessation of injection drug use (Des Jarlais & Seman, 2008; Riley et al., 2010; Rudolph et al.,2010a; Vlahov et al., 2010). Opioid agonist therapies (OAT) were developed to treat opioid dependence, which can involve long lasting physiological and molecular adaptations in the brain. One of the most widely used forms of OAT is methadone maintenance therapy. Methadone blocks the euphoric effects of other opioids and is associated with decreased illicit drug use (Strathdee & Patterson 2005; Vlahov, et al., 2000). Buprenorphine is another popular OAT used among IDUs who are HIV positive. Buprenorphine is safer for use in HIV infected persons receiving HAART because it has fewer drug interactions (Vlahov et al., 2010). Behavioral interventions focus on encouraging IDUs to refrain from risk behaviors (injection drug use, unprotected sex, and sharing drug paraphernalia) that can promote the spread of HIV. These interventions can reduce risk behaviors of IDUs at the level of the individual or social network (Freidman et al., 1999; Santibanez et al., 2006; Vlahov et al., 2010). Drug abuse treatment is the most widely endorsed intervention to reduce HIV-associated risks behaviors among IDUs

The HIV/AIDS epidemic rapidly spread and impacted women (Zierler & Kreiger, 1997) and urban communities of color during the period when epidemiological, government and media attention was focused almost solely on the gay population and injection drug users (Weeks et al., 1996). In 1981, six women in the United States were presented with an unexplained underlying cellular immune deficiency. These symptoms were similar to the phenomenon experienced by gay males in the United States that later lead to the official recognition of AIDS. Moreover, research indicates that between 1980 and 1981, 48 women died of AIDS related causes of death (Zierler & Kreiger, 1997). The potential magnitude of the female epidemic continued largely unremarked. Although men continue to represent the majority of new HIV cases, thirty years after the recognition of the disease the proportion of women infected with HIV/AIDS continues to rise.In 1985, women represented 8% of AIDS diagnoses; by 2005 they accounted for 27% (*Figure 4.1*) (CDC, 2007). In 1994, HIV/AIDS represented the third leading cause of death among women (Saul et al., 2000; Weeks et al., 1996;). The route of transmission for an overwhelming majority of new HIV cases among women is through heterosexual contact. The majority of the women infected with the virus

in the U.S. (*see section 4: Black and Latino women*).

**3.1 Interventions** 

(Strathdee & Patterson, 2005).

**4. Black and Latino women** 

are disproportionately women of color; African American and Latino women specifically. While blacks make up only 12% of the U.S. population, they represented nearly half of all people living with HIV in the U.S. in 2006 (46%, or 510,100 total persons). Sixty-four percent of all women living with HIV/AIDS are black. The prevalence rate for black women (1,122 per 100,000) was 18 times the rate for white women (63 per 100,000). Likewise, Hispanics/Latinos account for 15% of the U.S. population, but they accounted for 18% of people living with HIV in 2006 (194,000 total persons). The prevalence rate for Hispanic/Latino women (263 per 100,000) was four times the rate for white women (63 per 100,000) (CDC, 2008; Hall, 2008). An explanation for the disparity in the biological transmission of HIV among women of color is extricable bound to social and economic relations of class, gender, race, and sexuality (Zierler & Kreiger, 1997).

There is little difference in opportunistic processes or disease progression in women and men with HIV/AIDS (Gaskins, 2010). However, while heterosexual transmission of the HIV can occur both from males to females and from females to males (Gaskins, 2010), biologically women are more susceptible to contracting the virus (Fasula et al., 2009; Gaskins, 2010; Johnson & Johnstone, 1993; Minkoff et al.,1995;Nichols et al., 2002; Weeks et al,1996; Zierler & Krieger, 1997). There is increased biological efficiency of HIV transmission from the male to female in heterosexual intercourse (Campbell, 1999; Fasula et al., 2009, Minkoff et al, 1995). The proportion of AIDS cases in women attributed to sex with men rose steadily from 15% in 1983 to 38% in 1995 (Minkoff et al., 1995; Zierler &. Krieger, 1997). Today approximately 75%-85% of new HIV infections in women stem from heterosexual contact (Doherty et al, 2009; Fasula et al., 2009) *(figure 4.2)*. Susceptibility to HIV is further increased with the risk of trauma to cervical cells during intercourse (Gaskins, 2010; Nichols et al., 2002), and the presence of sexually transmitted diseases in women (ex. Human Papamoilla Virus (HPV), gonorrhea, Trichomonas vaginalis, chlamydia etc.) and other gynecologic infections,that can facilitate the acquisition of HIV (Gaskins, 2010: Sutton et al., 2009).

Impact of Socio-Medical Factors on the

contracting HIV.

**4.1 Interventions** 

Prevention and Treatment of HIV/AIDS Among Specific Subpopulations 297

White women. While incarcerated inmates are likely to be exposed to and/ or contract HIV, or become exposed to a pleura of risky behaviors which include risky drug use and tattooing practices and consensual and nonconsensual unprotected sexual intercourse (Fullilove, 2008 ). The HIV/AIDS epidemic is passed to the women in the sexual networks of inmates in these communities as inmates cycle from jails and prisons, back to the general

Yet another unique cultural artifact that influences the spread of HIV/AIDS among Black and Latino women are a bipartite of embedded gender inequalities and taboos toward homosexuality and bisexuality. Cultural roles can conflict with behaviors that can decrease the risk of HIV. In Latino communities the gender concept machismo/marianismo implies that household, public, as well as sexual decision making is dominated by men and women have very little power of refusal or negotiation ability (Davila, 2000; Flaskerud et al., 1996; Russell et al., 2000; Saul et al., 2000; Weeks et al, 1996). Moreover, traditional Latino culture emphasizes sexual activity by men and the avoidance of such activity by women (Flaskerud et al., 1996). Therefore Latino women may be especially at high risk of acquiring HIV heterosexually because Latino men are more likely to report multiple sex partners than other racial and ethnic groups (Saul et al., 2000). Within Latino culture, women-initiated sexual decisions, such as condom negotiation may be viewed as a challenge to male authority and trigger male resistance to condom use (Davila, 2000). While the popular image of the Black woman being independent, strong and assertive in their relations with Black men exists (Weeks et al., 1996), Black women face similar cultural restraints. The number of marriageable women far outweighs the number of marriageable men and results in Black women having relatively less power in their sexual relationships (Alleyne & Gaston, 2010; Doherty et al., 2009). Therefore, Black women's risk of contracting HIV increases owning to Black males' engagement in multiple concurrent sexual relationships, and black women's forced willingness to accept man sharing.These factors are further exacerbated by strong cultural beliefs that often stigmatize MSMs in Black and Latino communities. Homosexuality is culturally taboo in Black and Latino communities and is frequently viewed as "a sickness that afflicts only whites" (Bing & Soto, 1991). Consequently men in both minority groups may have great difficulty accepting their sexual orientation (Bing & Soto, 1991) and be secretive about their behavior, and not seek proper treatment for HIV/AIDS (Galanti, 2003). Because men who have sex with men (MSMs) may not identify themselves as homosexual or bisexual because (1); they are on the insertive not receptive end of anal sex (Galanti, 2003; Nichols et al., 2002; Russell et al, 2000 ); and (2) also engage in sex with women., they place their female partners at great risk. For example, a study showed that 34% of Black men who reported having sex with men also reported having sex with women, while only 6% of the women reported knowledge of having sex with a bisexual male (Brown & Hook, 2006). The confluence of gender inequalities and taboos toward homosexuality and bisexuality, limits opportunities for education, intervention, and treatment of HIV/AIDS, putting women in Black and Latino communities at risk of

Numerous complexities of race, culture, sexuality, religiosity, socioeconomic status, culture, and power affect HIV/AIDS risks and prevention for Black and Latino women. There exist gaps in the research literature and further gaps in research on gender and sexuality in the sociopolitical context of Black and Latino women (Fitzpatrick et al., 2006; Russell et al., 2000;

populous, and in many cases return to jails and prisons as recidivist (Fulliove, 2008).

Fig. 4.2. Estimated adult and adolescent new HIV diagnoses in 2009 by transmission route and gender.

Since most infections among women occur through heterosexual sex, their risk is predicated on the risk behaviors of their male partners and gender based-inequality. Abstinence is often not an option for women experiencing domestic violence or victims of sexual violence. Among women living with HIV infection nearly half reported forced sexual experiences (Zierler & Krieger, 1997).The fear of partner violence negatively affects a women's ability to protect themselves sexually (Gonzalez-Guards et al., 2008; Zierler & Krieger, 1997). Even in the absences of partner violence women's economic dependence on men (income, food, housing, child support, etc.) often makes negotiating condom use and safer sex practices difficult (Flaskerud et al, 1996; Gaskins, 2010; Gil, 1995; Saul et al, 2002; Weeks et al, 1996; Zierler & Krieger, 1997). Monogamous relationships can only offer protection if both partners have sex exclusively with each other and do not partake in other HIV/AIDS risk behaviors. Heterosexual intercourse with male partners who are substance abusers (specifically IDUs) helped facilitate the spread of HIV/AIDS amongst women (Campbell, 1999; Minkoff et al, 1995). About 48% of all AIDS cases are in women and are known to be related to IDU in some way (CDC, 2009). Similarly sexual contact with MSMs (who are married or in long term heterosexual relationships) has also heightened the spread of HIV amongst women (Campbell, 1999; .Minkoff et al, 1995).

Black and Latino women experience unique cultural factors that increase their vulnerability to HIV infection. One such issue relates to the high rates of incarceration in these communities and the impact on HIV transmission. Large numbers of incarcerated men creates a gender imbalance in these communities that can fuel HIV transmissions. US Bureau of Justice Statistics indicate that 60% of the 2.3 million incarcerated Americans are Black and Latino (Sabol & West, 2010). Additionally, Black males born in 2001 have 32% chance of going to jail compared to 17% chance for Latino males and 6% for White males. Thus, Black boys are five times and Latino boys nearly three times as likely as white boys to go to jail (Sabol & West, 2010). This trend is influenced greatly by the mandatory drug sentencing policies impacting low income minority communities. Disproportionate incarceration rates among African Americana and Latino men contribute to an imbalance in the ratio of men to women and thereby promote concurrent partnerships (Doherty et al., 2009). Concurrent sexual networks (partnerships overlap temporally) more efficiently promotes the spread of STDs and HIV (Doherty et al., 2009; Margolis et al., 2006). Moreover, incarceration and the "correctional revolving door" further explain the racial disparity in female HIV/AIDS infection rates amongst African American and Latino women versus

Fig. 4.2. Estimated adult and adolescent new HIV diagnoses in 2009 by transmission route

Since most infections among women occur through heterosexual sex, their risk is predicated on the risk behaviors of their male partners and gender based-inequality. Abstinence is often not an option for women experiencing domestic violence or victims of sexual violence. Among women living with HIV infection nearly half reported forced sexual experiences (Zierler & Krieger, 1997).The fear of partner violence negatively affects a women's ability to protect themselves sexually (Gonzalez-Guards et al., 2008; Zierler & Krieger, 1997). Even in the absences of partner violence women's economic dependence on men (income, food, housing, child support, etc.) often makes negotiating condom use and safer sex practices difficult (Flaskerud et al, 1996; Gaskins, 2010; Gil, 1995; Saul et al, 2002; Weeks et al, 1996; Zierler & Krieger, 1997). Monogamous relationships can only offer protection if both partners have sex exclusively with each other and do not partake in other HIV/AIDS risk behaviors. Heterosexual intercourse with male partners who are substance abusers (specifically IDUs) helped facilitate the spread of HIV/AIDS amongst women (Campbell, 1999; Minkoff et al, 1995). About 48% of all AIDS cases are in women and are known to be related to IDU in some way (CDC, 2009). Similarly sexual contact with MSMs (who are married or in long term heterosexual relationships) has also heightened the spread of HIV

Black and Latino women experience unique cultural factors that increase their vulnerability to HIV infection. One such issue relates to the high rates of incarceration in these communities and the impact on HIV transmission. Large numbers of incarcerated men creates a gender imbalance in these communities that can fuel HIV transmissions. US Bureau of Justice Statistics indicate that 60% of the 2.3 million incarcerated Americans are Black and Latino (Sabol & West, 2010). Additionally, Black males born in 2001 have 32% chance of going to jail compared to 17% chance for Latino males and 6% for White males. Thus, Black boys are five times and Latino boys nearly three times as likely as white boys to go to jail (Sabol & West, 2010). This trend is influenced greatly by the mandatory drug sentencing policies impacting low income minority communities. Disproportionate incarceration rates among African Americana and Latino men contribute to an imbalance in the ratio of men to women and thereby promote concurrent partnerships (Doherty et al., 2009). Concurrent sexual networks (partnerships overlap temporally) more efficiently promotes the spread of STDs and HIV (Doherty et al., 2009; Margolis et al., 2006). Moreover, incarceration and the "correctional revolving door" further explain the racial disparity in female HIV/AIDS infection rates amongst African American and Latino women versus

amongst women (Campbell, 1999; .Minkoff et al, 1995).

and gender.

White women. While incarcerated inmates are likely to be exposed to and/ or contract HIV, or become exposed to a pleura of risky behaviors which include risky drug use and tattooing practices and consensual and nonconsensual unprotected sexual intercourse (Fullilove, 2008 ). The HIV/AIDS epidemic is passed to the women in the sexual networks of inmates in these communities as inmates cycle from jails and prisons, back to the general populous, and in many cases return to jails and prisons as recidivist (Fulliove, 2008). Yet another unique cultural artifact that influences the spread of HIV/AIDS among Black and Latino women are a bipartite of embedded gender inequalities and taboos toward homosexuality and bisexuality. Cultural roles can conflict with behaviors that can decrease the risk of HIV. In Latino communities the gender concept machismo/marianismo implies that household, public, as well as sexual decision making is dominated by men and women have very little power of refusal or negotiation ability (Davila, 2000; Flaskerud et al., 1996; Russell et al., 2000; Saul et al., 2000; Weeks et al, 1996). Moreover, traditional Latino culture emphasizes sexual activity by men and the avoidance of such activity by women (Flaskerud et al., 1996). Therefore Latino women may be especially at high risk of acquiring HIV heterosexually because Latino men are more likely to report multiple sex partners than other racial and ethnic groups (Saul et al., 2000). Within Latino culture, women-initiated sexual decisions, such as condom negotiation may be viewed as a challenge to male authority and trigger male resistance to condom use (Davila, 2000). While the popular image of the Black woman being independent, strong and assertive in their relations with Black men exists (Weeks et al., 1996), Black women face similar cultural restraints. The number of marriageable women far outweighs the number of marriageable men and results in Black women having relatively less power in their sexual relationships (Alleyne & Gaston, 2010; Doherty et al., 2009). Therefore, Black women's risk of contracting HIV increases owning to Black males' engagement in multiple concurrent sexual relationships, and black women's forced willingness to accept man sharing.These factors are further exacerbated by strong cultural beliefs that often stigmatize MSMs in Black and Latino communities. Homosexuality is culturally taboo in Black and Latino communities and is frequently viewed as "a sickness that afflicts only whites" (Bing & Soto, 1991). Consequently men in both minority groups may have great difficulty accepting their sexual orientation (Bing & Soto, 1991) and be secretive about their behavior, and not seek proper treatment for HIV/AIDS (Galanti, 2003). Because men who have sex with men (MSMs) may not identify themselves as homosexual or bisexual because (1); they are on the insertive not receptive end of anal sex (Galanti, 2003; Nichols et al., 2002; Russell et al, 2000 ); and (2) also engage in sex with women., they place their female partners at great risk. For example, a study showed that 34% of Black men who reported having sex with men also reported having sex with women, while only 6% of the women reported knowledge of having sex with a bisexual male (Brown & Hook, 2006). The confluence of gender inequalities and taboos toward homosexuality and bisexuality, limits opportunities for education, intervention, and treatment of HIV/AIDS, putting women in Black and Latino communities at risk of contracting HIV.

#### **4.1 Interventions**

Numerous complexities of race, culture, sexuality, religiosity, socioeconomic status, culture, and power affect HIV/AIDS risks and prevention for Black and Latino women. There exist gaps in the research literature and further gaps in research on gender and sexuality in the sociopolitical context of Black and Latino women (Fitzpatrick et al., 2006; Russell et al., 2000;

Impact of Socio-Medical Factors on the

in The United States.

follow up (Grabar et al., 2006).

Prevention and Treatment of HIV/AIDS Among Specific Subpopulations 299

mediate the rising trend of a geriatric HIV positive population. Symptom ambiguity between HIV/AIDS infection and diseases associated with aging (such as diabetes mellitus, decreased renal function, and cardiac disease) often leading to misdiagnosis (Siegel et al., 1999; Zelentz & Epstein, 1998) and delays in diagnosing HIV. Moreover, due to physiologic changes associated with aging, there is a more rapid rate of progression of HIV to AIDS, and increased susceptibility to opportunistic illnesses in older adults (Gebo, 2006; Goodroad, 2003; Mack & Bland, 1999; Manfredi, 2002) (See figure 5). Other health challenges faced by older adults who are diagnosed with HIV include treatment complications due to comorbidities and polypharmacy (Grabar et al., 2006; Luther & Wilkin, 2007; McLennon, 2003).

Fig. 5. Concurrent HIV/AIDS among Persons Diagnosed With HIV in 2006, By Age Group

In addition to the issues associated with diagnosis of HIV, not too many advances have been made in the provision of effective HAART therapy, amongst older populations. Late diagnosis, impaired immune response, toxicities associated with HAART therapy and lack of knowledge about efficacy of HAART treatment among older adults contribute to high rates of mortality soon after diagnosis (Goetz et al., 2001; Mack & Bland, 1999; Manfredi & Chiodo, 2000; Nokes et al., 2000). Advanced age at seroconversion have always been important prognostic factors in the progression of HIV infection and survival mediated only by the widespread introduction of HAART therapy (Grabar et al., 2006; Manfredi, 2002). However, older patients are often excluded from clinical trials, and studies evaluating efficacy of HAART therapy in older adults are characterized by small numbers and short

Social issues surrounding HIV/AIDS in the older adult are just as important as the biomedical and pharmacotherapeutic aspects. Adults aged ≥50 experience a multidimensional form of HIV-related social stigma. Initially, ageist ideologies among many health care workers contribute to the general lack of understanding and recognition of HIV

Weeks et al., 1996; Zambrana et al., 2004). Moreover, this lack of knowledge limits coalition building, which is critical to HIV/AIDS prevention in women, among women in communities of color (Weeks, et al., 1996). To address these gaps in the research literature, limited enrollment in HIV clinical trials and limited treatment access, in 2003 the Center for Disease Control (CDC) created the Minority HIV/AIDS Research Initiative (Fitzpatrick et al., 2006). This program is designed to provide junior investigators assistance to conduct gap research in communities of color. The rationale for this program highlights the need to; (1) research HIV/AIDS in Black and Latino communities, (2); addressing evident research gaps can only be accomplished by understanding culture-specific nuances ascribed to Blacks and Latinos, and (3); the similarity between researcher and community would remove barriers to conducting effective research (Fitzpatrick et al., 2006). Weeks et al., highlight the need for indigenous female educators and organizers with an understanding of cultural issues to educate women of color about their risk potential (1996). Similarly, these women can also serve as principle investigators and direct research questions to build greater understanding of the social context within which Black and Latino women can make decisions and influence their sexual partners.
