**1. Introduction**

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

Vlassoff, C & Ali, F. (2011). HIV-related stigma among South Asians in Toronto, Ethnicity &

Adherence to treatment has been a matter of priority in the control of the HIV/AIDS epidemic. Due to the characteristics of the virus, adherence of at least 95% is necessary for the continuing suppression of the viral load, and to prevent the risk of AIDS progressing (Bangsberg et al., 2000). In view of the chronic nature of HIV/AIDS, and the benefits offered by antiretroviral therapy, a sufficient rate of adherence is essential for world public health.

There have been many efforts to control the behavior of people who suffer from HIV, in order to ensure that they follow their treatment instructions carefully. Nevertheless, in the conceptualization, research and intervention on the field of adherence, determinants of a general nature which could affect it have been seen as a minor issue.

Much of the research on HIV/AIDS adherence has been rooted in biomedical and behavioral approaches. Studied variables include age, gender, education (Carballo et al., 2004; Glass et al., 2006; Godin et al., 2005; Gordillo et al.,1999; Ickovics & Meade, 2002; Mocroft et al., 2001; Spire et al., 2002; Sternhell & Corr, 2002), health beliefs, coping styles, self-efficacy, control perception, stress, anxiety, depression (Chesney, 2000; Ingersoll, 2004; Turner-Cobb et al., 2002), pharmacological regimen, side effects, relationship with health care providers, geographical barriers, and social support (Burke et al., 2003; Chesney, Morin & Sherr, 2000).

Despite wide research on this topic, studies have not reach conceptual explanations about the relation between adherence to treatment in people diagnosed with HIV and structural determinants such as social position. Drawn from the current vision studying adherence, its definition has been limited to the degree that patients complete behaviors like following healthcare provider's instructions, taking antiretroviral medication and attending medical appointments. The gender perspective has also been restricted in spite of reports that compared to men, women face additional barriers including delays in medical attention, non-use of antiretroviral therapy, lack of financial support, poor quality of health care, and difficulties related to the doctor–patient relationship (Ickovics & Meade, 2002, Jia et al., 2004).

To complement the current biomedical and psychosocial view to the study of adherence in HIV cases, this chapter presents an approach from the social determinants of health focus. In

Social Position as a Structural Determinant

Organization [ILO], 2010).

of Adherence to Treatment in Women Living with HIV/AIDS 25

sector, where their income can vary from day to day, and where the lack of social support systems makes them more vulnerable to market variations. In this region the percentage of women who do not have their own income is between 37 and 50 (International Labor

However, gender inequity is also expressed in socially and culturally constructed gender roles. Women who live in patriarchal societies come up against exposure to what has been called the "triple feminine load", which determines the roles they carry out (Breilh, 1999). The first load consists of conditions such as informal work, with discrimination in tasks and positions; the second refers to the double shift that many women have, as a result of domestic work with their families. This double shift also includes an unequal and sexist distribution of work in the home, where the women look after the children, the cleaning, cooking, shopping among other things. The third load refers to the biological demands made on women's bodies due to their reproductive activity related to menstruation, pregnancy and lactation (Breilh, 1999). These three loads produce physical deterioration and result in having a differential affect on women's health, in comparison with that of men. Gender differences in health have been widely documented. There is sufficient evidence of this, and variations in life expectancy, the risk of morbidity and mortality, access to health services and treatment, the use of preventive health services and health behaviors have been found (Gómez, 2002; Payne, 2009). On a global level data shows that men experience higher mortality and a lower life expectancy than women, while women have a greater probability of higher morbidity and more years living with disability (Mathers et al, 2001; Payne, 2006). In the field of public health, for gender inequity to be reduced, what is required is the elimination of differences in the opportunities to enjoy good health, not to become ill, become disabled or die from preventable causes. In the case of women it is necessary to recognize that these differences are a reflection of: 1, different types of needs, 2, better use of health services, 3. differential patterns in the recognition of symptoms, perception of illness, and the way in which attention is sought, which are prevalent in different cultures, geographical regions, and socioeconomic status, and 4. the structural and institutional determinants of the health systems, which differentially facilitate or obstruct access to health services (Gómez, 2002; Weisman, 1998;). This situation is combined with roles as family caregivers, which obliges women, to a greater extent than men, to become familiar with

symptoms of illness, and as a consequence, seek more medical attention.

the development of health policies.

**2.2 Social position** 

enjoy them more.

The specific needs of women, their social position, the gender-based roles they assume in certain contexts, and the characteristics of the health systems to which they belong, highlight the importance of directing public policies with a gender mainstreaming approach, to promote their health and wellbeing. Health systems in particular have the commitment to promote gender equity and to reduce the gender gap in their daily operations as well as in

Social position can be defined as the "place" or social stratum of a person in the society in which they live. It is derived from a specific context, which means that the classification of the social position varies between societies with different economic structures (Diderichsen, et al., 2001). Throughout history it has been seen that in every society the most valued resources are distributed are unevenly distributed between the different social positions, and that individuals and families with occupy the more favored positions are those who

particular, the social position category is analyzed as a structural determinant of adherence of women affected by the virus. This proposal emerges before the need to understand not only the role of social position in adherence but also gender determinants that can affect it. An integral comprehension of adherence could promote the application of more effective interventions to achieve hoped for results.

The chapter begins with a section titled *gender, social position and health*, where these concepts are defined, and the problem of gender equity and inequity is considered together with their impact in the field of public health. A continuation called an *overview of vulnerabilities for women affected by HIV/AIDS* is presented giving a description on how women must face up to a wide range of political, economic and cultural determinants. The chapter subsequently shows data derived from a study carried out between 2006 and 2009 with 352 Colombian women who had been diagnosed with HIV. The data is analyzed based on a review of the literature which describes the associations between adherent behaviors and different variables related to social position. According to these results, the following section offers a *conceptual proposal of the social determinants of adherence to treatment* in HIV/AIDS, applicable to women affected by the virus, as well as describing its components. Finally, the chapter presents conclusions which summarize the arguments made throughout this study for the recognition of social position as a structural determinant of adherence to treatment in HIV/AIDS. It observes that debate, conceptualization and research into adherence are still not enough, and it stresses the need to continue to progress in a direction which would include the probable influence of determinations in a macro social context, such as poverty, inequity, violence, health systems, work, and food security, among others. Readers are invited to understand adherence in an all-embracing sense, to carry out new forms of intervention, focused on social and gender-related equity.

#### **2. Gender, social position and health**

#### **2.1 Gender equity and health**

It is well known that the "gender" category has been redefined in terms of a social and cultural construction, and not as a condition which derives from biological pertinence to one sex or another. On the contrary, gender determines different roles in society, which are transformed into inequities in the access to financial resources and the power which is exercised over them. *Gender equity* means fairness and justice in the distribution of benefits, power, resources and responsibilities between women and men (Breilh, 1999; Gómez, 2002; Kottak, 1994). As a counterpart, *gender inequity* represents a group of inequities which are considered to be unnecessary, avoidable, and apart from that, unfair (Whitehead, 1990), and which are associated with systematic disadvantages at socioeconomic level between men and women.

In socioeconomic terms, according to the International Labor Organization, inclusion in economic and social life is determined by gender. Also, this organization acknowledges that although the situation of women who work has improved, progress continues to be slow. In several regions women often face stronger barriers in the labor market, and female unemployment rates exceeded those for males. For example, of all the people employed in the world, only 40% are women; the rate of unemployment is higher in women than in men; employed women tend to be engaged in less productive sectors of the economy, have fewer opportunities to access the social security system, and are frequently receive lower salaries than men. In Latin America, around a quarter of the women are employed in the informal

particular, the social position category is analyzed as a structural determinant of adherence of women affected by the virus. This proposal emerges before the need to understand not only the role of social position in adherence but also gender determinants that can affect it. An integral comprehension of adherence could promote the application of more effective

The chapter begins with a section titled *gender, social position and health*, where these concepts are defined, and the problem of gender equity and inequity is considered together with their impact in the field of public health. A continuation called an *overview of vulnerabilities for women affected by HIV/AIDS* is presented giving a description on how women must face up to a wide range of political, economic and cultural determinants. The chapter subsequently shows data derived from a study carried out between 2006 and 2009 with 352 Colombian women who had been diagnosed with HIV. The data is analyzed based on a review of the literature which describes the associations between adherent behaviors and different variables related to social position. According to these results, the following section offers a *conceptual proposal of the social determinants of adherence to treatment* in HIV/AIDS, applicable to women affected by the virus, as well as describing its components. Finally, the chapter presents conclusions which summarize the arguments made throughout this study for the recognition of social position as a structural determinant of adherence to treatment in HIV/AIDS. It observes that debate, conceptualization and research into adherence are still not enough, and it stresses the need to continue to progress in a direction which would include the probable influence of determinations in a macro social context, such as poverty, inequity, violence, health systems, work, and food security, among others. Readers are invited to understand adherence in an all-embracing sense, to carry out new forms of

It is well known that the "gender" category has been redefined in terms of a social and cultural construction, and not as a condition which derives from biological pertinence to one sex or another. On the contrary, gender determines different roles in society, which are transformed into inequities in the access to financial resources and the power which is exercised over them. *Gender equity* means fairness and justice in the distribution of benefits, power, resources and responsibilities between women and men (Breilh, 1999; Gómez, 2002; Kottak, 1994). As a counterpart, *gender inequity* represents a group of inequities which are considered to be unnecessary, avoidable, and apart from that, unfair (Whitehead, 1990), and which are associated with systematic disadvantages at socioeconomic level between men

In socioeconomic terms, according to the International Labor Organization, inclusion in economic and social life is determined by gender. Also, this organization acknowledges that although the situation of women who work has improved, progress continues to be slow. In several regions women often face stronger barriers in the labor market, and female unemployment rates exceeded those for males. For example, of all the people employed in the world, only 40% are women; the rate of unemployment is higher in women than in men; employed women tend to be engaged in less productive sectors of the economy, have fewer opportunities to access the social security system, and are frequently receive lower salaries than men. In Latin America, around a quarter of the women are employed in the informal

interventions to achieve hoped for results.

intervention, focused on social and gender-related equity.

**2. Gender, social position and health** 

**2.1 Gender equity and health** 

and women.

sector, where their income can vary from day to day, and where the lack of social support systems makes them more vulnerable to market variations. In this region the percentage of women who do not have their own income is between 37 and 50 (International Labor Organization [ILO], 2010).

However, gender inequity is also expressed in socially and culturally constructed gender roles. Women who live in patriarchal societies come up against exposure to what has been called the "triple feminine load", which determines the roles they carry out (Breilh, 1999). The first load consists of conditions such as informal work, with discrimination in tasks and positions; the second refers to the double shift that many women have, as a result of domestic work with their families. This double shift also includes an unequal and sexist distribution of work in the home, where the women look after the children, the cleaning, cooking, shopping among other things. The third load refers to the biological demands made on women's bodies due to their reproductive activity related to menstruation, pregnancy and lactation (Breilh, 1999). These three loads produce physical deterioration and result in having a differential affect on women's health, in comparison with that of men.

Gender differences in health have been widely documented. There is sufficient evidence of this, and variations in life expectancy, the risk of morbidity and mortality, access to health services and treatment, the use of preventive health services and health behaviors have been found (Gómez, 2002; Payne, 2009). On a global level data shows that men experience higher mortality and a lower life expectancy than women, while women have a greater probability of higher morbidity and more years living with disability (Mathers et al, 2001; Payne, 2006). In the field of public health, for gender inequity to be reduced, what is required is the elimination of differences in the opportunities to enjoy good health, not to become ill, become disabled or die from preventable causes. In the case of women it is necessary to recognize that these differences are a reflection of: 1, different types of needs, 2, better use of health services, 3. differential patterns in the recognition of symptoms, perception of illness, and the way in which attention is sought, which are prevalent in different cultures, geographical regions, and socioeconomic status, and 4. the structural and institutional determinants of the health systems, which differentially facilitate or obstruct access to health services (Gómez, 2002; Weisman, 1998;). This situation is combined with roles as family caregivers, which obliges women, to a greater extent than men, to become familiar with symptoms of illness, and as a consequence, seek more medical attention.

The specific needs of women, their social position, the gender-based roles they assume in certain contexts, and the characteristics of the health systems to which they belong, highlight the importance of directing public policies with a gender mainstreaming approach, to promote their health and wellbeing. Health systems in particular have the commitment to promote gender equity and to reduce the gender gap in their daily operations as well as in the development of health policies.

#### **2.2 Social position**

Social position can be defined as the "place" or social stratum of a person in the society in which they live. It is derived from a specific context, which means that the classification of the social position varies between societies with different economic structures (Diderichsen, et al., 2001). Throughout history it has been seen that in every society the most valued resources are distributed are unevenly distributed between the different social positions, and that individuals and families with occupy the more favored positions are those who enjoy them more.

Social Position as a Structural Determinant

expectancy (Navarro, 2004; Raphael 2003).

different from those of men.

(Poundstone et al., 2004).

position is exacerbated by gender inequity.

**3. Overview of vulnerabilities for women with HIV/AIDS** 

of Adherence to Treatment in Women Living with HIV/AIDS 27

For its part, as far as *education* as a determinant associated to social position is concerned, there is sufficient data to show that each unit of increase in educational level or professional hierarchy is accompanied by a corresponding increase in the final health outcomes (Dahlgren & Whitehead, 1992); the probability of survival is greater in persons in social positions with higher educational levels. And with regard to *work/employment*, it has traditionally been suggested that the relationship between employment and health is based on whether people can earn sufficient income to support themselves, have access to resources and be productive (Benach & Muntaner, 2007; Raphael, 2004). The unemployed population presents higher mortality rates, while job security has an effect on life

In a global context, the growth in the number of women who work outside their homes in paid jobs has brought about qualitative changes in their political, legal, economic and social situation. In the private sphere, employment has an effect on the material conditions in which women live their lives on a day-to-day basis, their ability to negotiate in their marital and family relationships, the possibility of achieving economic independence and in their self-esteem as individuals. Nevertheless, social position as a category of analysis helps in the understanding of the connection which exists between one's place in the world of work, the social and cultural characteristics and the relationship of this position with gender inequities. The working world of women cannot be understood only as employment or unemployment from a traditional approach. This vision does not take into account different occupations and "ways of earning a living" that women have, such as informal and domestic work. The type of work done by women determines gender roles, and as Breilh (1999) has stated, has an impact on women's health with patterns of deterioration which are

As has already been mentioned, conditions of gender inequity place women in positions of disadvantage in comparison with men, making them more vulnerable. The vulnerability approach has attracted attention with regard to the structural conditions which place women in a position of risk, beyond that of their "irresponsible" individual behavior in relation to HIV infection. Women must face a broad spectrum of political, economic and cultural determinants which affect the way in which they can protect themselves against infection, deal with the virus once they have been affected, or look after family members who are affected. In fact, a meta-analysis of research carried out in the field of social epidemiology in HIV/AIDS between 1981 and 2003 revealed that to be a woman is one of the determinants of structural violence and discrimination related with the infection

Some of the conditions of vulnerability of women infected with HIV are described below. **Poverty.** It is no secret that HIV has spread uncontrollably throughout the world, but not by chance; on the contrary it is intensified within the ranks of the poor and those who are powerless, such as women (Farmer, 2000). In this way, poverty has become a structural determinant which is clearly connected to the epidemic, and acts as a booster of the virus. Women in situations of poverty have few opportunities with respect to education, work, nutrition, and housing. They run a greater risk of infection and have limited care options at their disposal once they have been diagnosed with HIV. In this case inequity by social

It is important to point out that the concepts of "socioeconomic level" and "socioeconomic status" are often used as synonyms for social position, but they have no explicit relationship with the economic and political forces which explain the lack of social and gender-based equity. Neither can social position be compared with the concept of "social class" in the style of Marx or Weber, since in its most classical sense this concept cannot but accept the transversal capacity that gender has as a category, not only in the differentiation of experiences between men and women, but also between women of different social positions. The relationship between social context and the manner in which people are distributed among certain social positions is a determinant of the health outcomes. At the same time, social position is influenced by other variables, such as the health network to which individuals have access, their academic level, and occupation or "earning a living".

In countries lacking complete universal access to health insurance or health services, people and families must absorb the direct costs of health care themselves (Dahlgren & Whitehead, 2007; Navarro, 1989). Although this phenomenon affects people of all social positions in the same way, their ability to deal with these costs is extremely varied, depending on the socioeconomic situation (Diderichsen, et al., 2001). In general, those who belong to the wealthier sectors are able to absorb more costs, often have private insurance policies, and will probably not get into serious debt in order to pay their health costs. For its part, the economic safety net of the poorest groups is smaller, these people are less likely to be able to pay for private health insurance and they are often obliged to find new sources of income produced by other members of the family, or become seriously indebted. Non-universal health systems may impose impoverishing charges on those who are able to use them, making the already existent inequities in their living conditions even worse (Borrell et al., 2007). Ill-health may commence an ascending spiral of excessive costs as a result of health care and the loss of income derived from work.

Women in particular are limited, as far as opportunities in the labor market are concerned; their ability to pay is less, but despite this they pay more than men for their medical costs. Health financing systems which require high out-of-pocket payments increase their outgoings, when added to their basic needs and use of services (Borrell et al., 2007). Access to health insurance is still more limited, because of the interruptions in their work, due to pregnancy and the raising of their children. Apart from this, the nature of "dependents" in insurance, places them at risk of being unprotected in the event of widowhood, abandonment, marital separation, changes in the employment situation of their partner, or changes in the regulations which govern the coverage of dependents. The fact that over 30% of homes in regions such as Latin America have women as heads of household (Pan American Health Organization [PAHO], 2009) serves as an indicator of their vulnerability.

Gender analysts have pointed out that health costs have a devastating effect on economies which are managed by women. When a woman becomes ill and at the same is head of the household, the family income which is destined for food, education and health care for children, is reduced (Payne, 2009). In the case of HIV/AIDS the effects have obviously been financially ruinous (International Community of Women Living with HIV/AIDS [ICW], 2005). It is thus accurate to conclude that the principle of gender-based equity in health, according to which the amount payable would be linked to the people's capacity to pay, is considerably threatened in the case of women, especially in the case of non-universal health systems, and are restricted to social security networks.

It is important to point out that the concepts of "socioeconomic level" and "socioeconomic status" are often used as synonyms for social position, but they have no explicit relationship with the economic and political forces which explain the lack of social and gender-based equity. Neither can social position be compared with the concept of "social class" in the style of Marx or Weber, since in its most classical sense this concept cannot but accept the transversal capacity that gender has as a category, not only in the differentiation of experiences between men and women, but also between women of different social positions. The relationship between social context and the manner in which people are distributed among certain social positions is a determinant of the health outcomes. At the same time, social position is influenced by other variables, such as the health network to which

individuals have access, their academic level, and occupation or "earning a living".

care and the loss of income derived from work.

systems, and are restricted to social security networks.

In countries lacking complete universal access to health insurance or health services, people and families must absorb the direct costs of health care themselves (Dahlgren & Whitehead, 2007; Navarro, 1989). Although this phenomenon affects people of all social positions in the same way, their ability to deal with these costs is extremely varied, depending on the socioeconomic situation (Diderichsen, et al., 2001). In general, those who belong to the wealthier sectors are able to absorb more costs, often have private insurance policies, and will probably not get into serious debt in order to pay their health costs. For its part, the economic safety net of the poorest groups is smaller, these people are less likely to be able to pay for private health insurance and they are often obliged to find new sources of income produced by other members of the family, or become seriously indebted. Non-universal health systems may impose impoverishing charges on those who are able to use them, making the already existent inequities in their living conditions even worse (Borrell et al., 2007). Ill-health may commence an ascending spiral of excessive costs as a result of health

Women in particular are limited, as far as opportunities in the labor market are concerned; their ability to pay is less, but despite this they pay more than men for their medical costs. Health financing systems which require high out-of-pocket payments increase their outgoings, when added to their basic needs and use of services (Borrell et al., 2007). Access to health insurance is still more limited, because of the interruptions in their work, due to pregnancy and the raising of their children. Apart from this, the nature of "dependents" in insurance, places them at risk of being unprotected in the event of widowhood, abandonment, marital separation, changes in the employment situation of their partner, or changes in the regulations which govern the coverage of dependents. The fact that over 30% of homes in regions such as Latin America have women as heads of household (Pan American Health Organization [PAHO], 2009) serves as an indicator of their vulnerability. Gender analysts have pointed out that health costs have a devastating effect on economies which are managed by women. When a woman becomes ill and at the same is head of the household, the family income which is destined for food, education and health care for children, is reduced (Payne, 2009). In the case of HIV/AIDS the effects have obviously been financially ruinous (International Community of Women Living with HIV/AIDS [ICW], 2005). It is thus accurate to conclude that the principle of gender-based equity in health, according to which the amount payable would be linked to the people's capacity to pay, is considerably threatened in the case of women, especially in the case of non-universal health For its part, as far as *education* as a determinant associated to social position is concerned, there is sufficient data to show that each unit of increase in educational level or professional hierarchy is accompanied by a corresponding increase in the final health outcomes (Dahlgren & Whitehead, 1992); the probability of survival is greater in persons in social positions with higher educational levels. And with regard to *work/employment*, it has traditionally been suggested that the relationship between employment and health is based on whether people can earn sufficient income to support themselves, have access to resources and be productive (Benach & Muntaner, 2007; Raphael, 2004). The unemployed population presents higher mortality rates, while job security has an effect on life expectancy (Navarro, 2004; Raphael 2003).

In a global context, the growth in the number of women who work outside their homes in paid jobs has brought about qualitative changes in their political, legal, economic and social situation. In the private sphere, employment has an effect on the material conditions in which women live their lives on a day-to-day basis, their ability to negotiate in their marital and family relationships, the possibility of achieving economic independence and in their self-esteem as individuals. Nevertheless, social position as a category of analysis helps in the understanding of the connection which exists between one's place in the world of work, the social and cultural characteristics and the relationship of this position with gender inequities. The working world of women cannot be understood only as employment or unemployment from a traditional approach. This vision does not take into account different occupations and "ways of earning a living" that women have, such as informal and domestic work. The type of work done by women determines gender roles, and as Breilh (1999) has stated, has an impact on women's health with patterns of deterioration which are different from those of men.
