HIV Infections and African-American Women - Essay Example

Running head: HIV/AIDS, Homelessness, and Poverty African-American Women: Dying to Live Felecia A. Bailey of Maryland Gradate School of Nursing Comprehensive Examination Dr. Susan Wozenski October, 27, 2007 Abstract Acquired Immunodeficiency Syndrome (AIDS) and its causative agent, Human Immunodeficiency Virus (HIV), have challenged scientists and society as a whole for more than two decades. Since the disease was first diagnosed in 1981, approximately 1.7 million people in the United States have been infected with the virus. In the United States and abroad, minority women, and African-American women in particular, are disproportionately affected by the HIV epidemic, with African-American women being diagnosed with HIV at a significantly higher rate than other groups. In order to manage this epidemic, CDC and other public health practitioners generally apply individual based theories. However, individual based theories are inadequate because they assume that an individual is fully equipped to make the necessary behavior changes that have been suggested. These theories have a propensity to overlook at the individuals' environment, socio-economic status, shelter accessibility, and various other circumstances as they relate to the prevention of high-risk behaviors. This paper will specifically define how poverty and homelessness serve as explanations for the increased incidence and prevalence of HIV in the African-American community, and African-American women in particular. Key Words: African-American, Women, HIV, Homelessness, Poverty Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) have challenged scientists, researchers, health professionals, and general society for more than twenty years. The greatest challenge for scientists and researchers has been to develop a vaccine for the virus, while for health professionals and society as a whole, the challenge has been in the prevention of new HIV infections. Thus far, development of a successful vaccine has been prevented due to the ability of the virus to effectively evade any immune-mediated strategies that are directed against it. With nine known genetic subtypes, HIV is already genetically diverse, and new strains continue to emerge, making vaccine development even more difficult. In essence, the high mutation rate of HIV means that scientists are attempting to hit a target that is constantly moving (Tonks, 2007). On the other hand, as knowledge of the virus and its associated syndrome increases, those who are infected are living longer and experiencing better quality of life than was possible even ten years ago. With improved medication and more advanced approaches to treatment, HIV has become more a chronic condition than an immediate death sentence. Prior to acting on a decision to advance my education and pursue a Master's degree in Community/Public Health Nursing, I developed an aspiration to involve myself actively in the mission to find a vaccination, cure, or even a more effective preventative strategy for HIV. As a member of the United States Public Health Service and an employee of the Federal Bureau of Prisons, I was quickly introduced to HIV on a massive scale. In the United States, eight million individuals pass through correctional systems every year (Boutwell & Rich, 2004). Due to the increasing imprisonment of drug users and the disproportionate incarceration of minorities, the number of people with HIV or AIDS behind bars in the U.S. is more than three times higher than in the general population (Ammon & McLemore, 2007). As inmates in the prison system are predominantly African-American and account for the majority of HIV diagnoses, I began to wonder about how many of the girlfriends and wives who visited daily knew about the HIV status of their partners. On their release, would those inmates eventually infect their loved ones It was during this time that I realized that the belief that HIV largely affected homosexual Caucasian males was a serious misconception. The reality was that these black men dated predominantly black women. Once released the inmate would without a doubt have unprotected sex with his partner and expose her to the virus. Hence, as a result of my exposure to HIV in the prison setting, I quickly became conscious of the serious nature of this issue, and the need for public health officials to embark on strategies that do not solely preach prevention. The first cases of what would later become known as AIDS were reported in the United States in June of 1981 (Smith et al., 2000). Initially, gay white men accounted for the majority of HIV/AIDS cases. Since that time, approximately 1.7 million people in the United States have been infected with HIV, including more than 550,000 who have already died. There are an estimated 1.2 million people living with HIV/AIDS in the United States today, representing 2.5% of the total number of people with the disease worldwide (Hariri & McKenna, 2007). African-Americans account for a disproportionate share of new AIDS diagnoses (Figure 1) ("HIV/AIDS Surveillance Report: The HIV/AIDS Epidemic in the United States," 2007). In the United States, the annual number of estimated AIDS cases increased by 15% among women but only 1% among men from 1999 to 2003. The major burden of disease was in young women of color, particularly African-American women. The rate of AIDS diagnosis for African-American women was approximately twenty-five times higher than the rate for white women and four times the rate for Hispanic women (Quinn & Overbaugh, 2005). Figure 1: AIDS Diagnoses & US Population, by Race/Ethnicity, Despite the progress made in decreasing the incidence and prevalence of HIV/AIDS in the Caucasian community, the public health workforce has not been successful in reaching the same level of improvement for the African-American community, and for African-American women in particular. As public health leaders who contribute to the mission of preventing new transmissions, promoting health, and meeting the needs of underserved populations, we must ask difficult questions and seek to answer them. Specifically we must ask why, after so much advancement in the area of HIV/AIDS prevention for certain ethnic groups, are African-American women suffering from this disease at such a disproportionate rate. What unmet needs of African-American women are contributing to their high rates of transmission What must public health workers do in order to reach this population and make changes that will effectively reduce the transmission rate Current research shows that African-American women are more at risk for HIV infection than any other ethnic group, strongly suggesting that there are specific issues relating to this group that have lead to increased HIV transmission rates. While current research does pinpoint some issues that contribute to the increased transmission rate in African-American women, no solutions have yet been presented. In addition, the literature does not suggest any ways in which the needs of these women can be met that might result in a significant decrease in both the incidence and the prevalence of HIV in this population. Public health officials are unquestionably aware that high-risk behaviors such as intravenous drug use and unprotected sex with multiple partners vastly increase the risk of being infected with HIV. However, it is also true that while educating the public is crucial to preventing the spread of the virus, it is clearly not sufficient to simply disseminate this informationn. Keeping in mind the important fact that this disease is preventable, an even more crucial step is determining why individuals are not complying with the prevention messages they receive from community and public health practitioners. Given that HIV is an extremely high profile disease, why do African-American women continue to participate in high-risk behaviors Why are they not protecting themselves by using condoms when their most common mode of transmission is through heterosexual contact How can we enhance the prevention strategies that are available Even more importantly, should prevention be the area of focus in this situation In general, literature that focuses on HIV prevention advocates strategies that promote changing high-risk behaviors (Brown & Hook, 2006). In our efforts to promote behavioral change, it is common for researchers, nurses, and public health advocates to look to such literature for recommendations. Ultimately it is theory that inspires our questions and enables us to envision a far healthier world than the one in which we live. In the case of HIV prevention, the most common high-risk behaviors relevant to African-American women are drug use and unprotected heterosexual sex. In terms of HIV/AIDS, public health officials have based behavioral change intervention strategies on theories such as Individual Behavioral Change Theories and Health Belief Models. There have been many individual behavioral change theories and health belief models developed specifically for African-American women with the purpose of preventing HIV transmission; two examples include the CDC's new imitative plan, and the African-Centered Behavioral Change Model. However, I believe these approaches neglect a crucial first step that almost entirely negates their value. These models attempt to change behavior on an individual level without developing an understanding of why individuals participate in high-risk and potentially harmful behaviors. Current statistics indicating the increase in incidence and prevalence of HIV in African-Americans suggest that such approaches are failing. As part of new efforts to address the HIV epidemic in African-Americans, the CDC has increased opportunities for diagnosis and treatment, and is committed to expanding the number of available risk reduction interventions that are tailored to African-Americans. The CDC will require organizations receiving HIV-prevention funding to use one of the evidenced-based interventions on a list called the Diffusion of Effective Behavioral Interventions (DEBI) (Young, 2007). However, there are only thirteen interventions on the DEBI list and only a small number of these were designed for the African-American community. According to one CDC representative: "One of the key things we're encouraging especially for healthcare providers, is increasing the opportunities for diagnosis and treatment. As part of the African-American heightened response, we're encouraging all African-Americans, ages 16 to 64 to get tested." (Young, 2007). Half of the money allocated for prevention programs will be used to increase testing and counseling in the belief that in order to reduce new infections, it is critical for individuals to know their HIV status. The CDC is providing thirty million to thirty-five million dollars to state and local health departments to increase testing in their jurisdictions, and this money is going to areas where the HIV rate among African-Americans is highest. Although it is essential to encourage individuals to undergo HIV testing, I believe that it is most important to allocate some of the monies that will be used for testing towards addressing the root causes of the HIV epidemic. The CDC's efforts are commendable, but they do not address the underlying issues that have contributed to increased HIV transmission rates. The African-Centered Behavioral Change Model (ACBC), for example, addresses the idea that the best prevention strategy is a plan that promotes positive development rather than prevention of a particular dysfunctional behavior (Gilbert & Goddard, 2006). Components incorporate individual and relational responses to oppressive structural forces, including how negative stereotyping and distorted perceptions of one's peer or ethnic group weakens self-regard and group pride and creates internalized oppression. This model, although African-American based, is focused primarily on prevention strategies. Its goal is to increase self-worth and racial pride, and to decrease depression and substance abuse. However, while the ACBC model's approach is a reflection of true-life circumstances for African-American women, it still does not address the underlying causes of their circumstances. The core barriers it identifies for African-American women include poor self-worth, depression, and poor perception of future quality of life. Its goals are to increase a person's vigilance around health promotion and reduce high-risk behavior. Again, its efforts are commendable, but if the barriers that African-American women must overcome during every day life are not addressed, improving self-worth, changing their poor perception of the future, and attempting to relieve them of depression will all be in vain. While HIV/AIDS health prevention and promotion strategies on the individual level are indeed valuable and necessary, it is all too possible that the strategies currently in use exclude the greater part of the female African-American population. These women do not benefit simply from knowing their HIV status. In addition, health belief and behavioral models do not take into account simple but essential and often-overlooked factors such as how those with the greatest need can actually access HIV tests. A woman who cannot afford to take public transport to visit a free CDC-funded clinic will simply not take advantage of the opportunity. The second issue is that people who are tested and found HIV positive are by no means assured of receiving proper care and treatment. In such cases, who has really benefited from the diagnosis-the individual, or the CDC and epidemiologists who study the disease Finally, individual health promotion strategies and health belief models do not allow for the possibility that testing may not be a priority for all individuals at risk of HIV. While I believe that the behavioral change theory works well for individuals who are capable of making the changes that are indicated in their situations, this theory is not all-inclusive. It works for people engaging in high-risk behavior only if they have the resources that will allow them to modify their behavior. For people who do not have access to quality health care, behavioral change theory is much less effective, and these types of theories should not be the foundation that nurses, researchers, and community/public health workers rely on. A more effective alternative might be an ecosocial multi-level framework. Ecosocial and other multi-level frameworks seek to integrate social and biological reasoning with a dynamic, historical, and ecological perspective. This type of strategy more effectively allows for the development of new insights into determinants of population distributions of disease and social inequalities in health (Krieger, 2001). As previously mentioned, the most significant issue with individual based health promotion and prevention initiatives (education, testing, increasing awareness, motivation) is that they tend to overlook primary explanations for the increase in incidence and prevalence of HIV in African-American women. Two determinants that are indicated as major contributors are poverty and homelessness. Poverty is defined as a condition in which a person or community is deprived of or lacks the essentials for a minimum standard of living and well-being. I believe it can also be seen as a symbol of society's failure to meet Maslow's Hierarchy of basic needs (food, water, and shelter), and perhaps even as a symbol of oppression. Gershman, Irwin, and Shakow informs us that our understanding of poverty must include not only the lack of basic economic resources (including money and food), but also on how material deprivation leads to poor health and lack of social resources, including access to education and health (Hofrichter, 2003, p. 157). One fifth of the world's population (around 1.3 billion human beings) survives on less than one dollar per day. Another 1.8 billion people live on only two dollars per day (Hughes, 2007). African-Americans accounted for the largest percentage of poverty at 24.9%, followed by Hispanics at 21.8% ("Income Climbs, Poverty Stabilizes, Uninsured Rate Increases," 2006). It is also estimated that as many as 3.5 million people are homeless during any given year, and that at least 3% of these may have HIV/AIDS. Some studies indicate that the prevalence of HIV among homeless people is as high as 20% ("HIV/AIDS and Homeless Fact Sheet"). Every human being deserves a fair chance at life, regardless of race, creed, or color. Paul Farmer states: "Many of the groups of people living on the wrong side of the great epi divide have brown or black skin. What they all have in common is poverty." (Kidder, 2003, p. 125). Unfortunately for many African-Americans, poverty begins at birth, having been born into poverty due to political systems that determine the position of the epi divide. The odds are against them from the moment of conception and for most there is only a very small chance that they will beat those odds and make it successfully out of a life of poverty that may have begun several generations ago. Severe and unrelenting poverty decides the fate for such people at an early age, and more often than not this is a life that may include single-parent homes, poor education, violence, drug use, crime, imprisonment, and homelessness. This vicious cycle of poverty that affects increasing numbers of African-American women places them in situations where they must risk death in order to live. Such risks include living with abusive parents or partners, practicing prostitution, using intravenous and other drugs to numb the reality of their current state, and more specifically, living with HIV positive partners. The reality is that an additional income made on the streets selling drugs will put food on the table and a roof over the head. In the eyes of a woman who lives this life every day, it is more desirable than being hungry and living on the streets. According to the most recent report from Market Watch, even those who are able to work have difficulty meeting basic needs, and approximately forty-one million people in working families cannot afford such basic necessities as health care and housing. Ironically, many of these people earn too much to qualify for family support aids such as Medicaid and food stamps, but their employer-provided health insurance does not cover enough of their basic medical needs (Mantell, 2007). If individuals who actually have jobs find it difficult to make ends meet, one can only imagine how difficult it must be for an individual without employment to survive. Many people who do not have to live such lives believe that the attraction of prostitution or drug dealing lies in the ability to make fast cash for luxury items, but in fact, for many people this is a means of survival in a world where no other help is available. African-American women living in conditions of extreme poverty are more likely to have multiple or casual sexual partners, and are less likely to be in stable and exclusive long-term relationships. While it can be argued that all women of all races face similar situations and hardships when living in poverty, the fact that African-American women experience such hardships on a larger scale and a more consistently long-term basis cannot be refuted. Women living in poverty, particularly women of color who live in urban areas, are among those at greatest risk of becoming infected with HIV (Kalichman, et al 1998). For this sole reason, poverty and homelessness or unstable housing must be addressed in any attempt to understand why African-American women continue to participate in high-risk behaviors despite having knowledge of the potential dangers. If one can envision a human being beginning her day waking up on the pavement with newspapers serving as pillows and blankets, and experiencing the same hunger pangs that she fell asleep with, they will have envisioned only a tiny part of the tribulations that homeless women experience on a daily basis. Imagine her having no way of caring for the bumps and bruises she received the night before because she did not bring the expected amount of money to the man who forces her to sell her body. Imagine her hungry and in pain while recollecting the childhood of sexual, physical or psychological abuse that made her run away from home with nowhere to go besides the streets, and grimly realizing that she still has nowhere else to go. A bleak picture, but one that is a reality for too many women, and one that serves to illustrate factors that cause women to continue engaging in high-risk behavior even when they fully understand the potential consequences. A recent longitudinal study demonstrates that worsening housing status is associated with increased risk sexual behavior (Wenzel & Tucker, 2006). Realizing that most of these women are forced to engage in high-risk behaviors and do not simply choose their lifestyle is important to understanding why the incidence and prevalence of HIV/AIDS continues to increase. The ability to negotiate safer sex with a partner who offers food, shelter, or protection is not always an option. Poverty, homelessness, and housing instability are significant public health and social justice issues that increase the risks of HIV acquisition and transmission. Eighty percent of America's homeless are African-American (Laurence, 2002), and a study conducted in Philadelphia reports that homelessness and AIDS frequently co-occur. People with AIDS were observed to be three times as likely to have been homeless than the general population. More African-American people are admitted to shelters than any other race, and accounted for 90% of people in Philadelphia shelters (Culhane D. et al, 2001). Based on this study and others of its kind, it is safe to say that homeless people or shelter users represent a very high-risk subpopulation for acquiring HIV and developing AIDS. Homeless women are very often so desperate to secure food and shelter that they are unable to focus on protecting themselves from HIV, simply because hunger and homelessness are more immediate and pressing problems. Gurung conducted a study to research the variables of the chronic burdens of women at risk for HIV/AIDS. When questioned about her fear of being infected with HIV, one participant responded: "You know, HIV is not my biggest problem" (Regan & Gurung, 2004). Becoming HIV positive is only an additional problem that compounds the other issues such women must deal with. While conducting a focus group of my own with a People Living with HIV/AIDS support group in Baltimore, MD, one member of the group made the issue of personal safety very clear: "When I was out on the streets with nowhere to live, my problem was trying to figure out where I was going to sleep tonight. If I had to have sex with someone to have a place for the night, then I had to do what I had to do. When you are on the streets with nowhere to live, you are not thinking about getting HIV." Elifson reports that people who are homeless or unstably housed are less likely to reduce their HIV risk than those who have stable homes. His findings have important implications for HIV prevention efforts as they show that it is more difficult to motivate behavioral change in people who are struggling with the myriad of challenges associated with being homeless or unstably housed (Wolitski, et. al, 2007). Sadly, some women may find it is more beneficial to be diagnosed with HIV, because only then will they be able to qualify for housing and healthcare according to some Ryan White funding requirements. Preventing HIV infection is much more complicated than educating people about abstinence, being faithful to a partner, negotiating condom use or having access to testing and counseling. Since the most common barriers to HIV prevention have been exposed, the question to be answered now is how do we appropriately assess the dire situations that many African-American women face Program planning for any community requires appropriate assessment prior to implementing change. It is not necessarily our responsibility to educate this population about what it needs in order to prevent HIV transmission. Instead, we must allow them to educate us about what their needs are. This information should come from the people themselves-from women living on the streets, from people who attend PLWA meetings, via communication with collaborators and coalition builders, and from other reliable community sources. I firmly believe that an assessment of those who are considered most high-risk for HIV would show that issues such as self-worth, getting tested for HIV to determine their status, and using condoms every time they had sex would not be at the top of their list of needs and solutions to the HIV problem. Instead, they are more likely to name issues such as shelter, food, clothing, money for rent, childcare, healthcare, transportation, employment, and the ability to care for themselves without depending on a "pimp" or other abuser. Effective HIV prevention requires nothing less than community health strategies and social justice advocacy policies that recognize the roles of culture, power, and gender relations in the well-being of African-American women. Furthermore, to succeed in the quest for reducing the incidence and prevalence of HIV/AIDS in African-American women, intervention strategies must work towards meeting more basic needs such as food, housing, and sanitation to mitigate the effects of poverty (Hughes, 2007). These are far more pressing needs that women must have consistent access to before they can begin to modify their own high-risk behavior patterns and protect themselves from HIV infection. References 1. Amman, J., & McLemore, M. (2007, May 10). Curb HIV infection rates in Texas prisons. In Defending human rights worldwide. Retrieved October 4, 2007, from Human Rights Watch: http://hrw.org/english/docs/2007/05/15/usdom15939.htm. 2. Boutwell, A., & Rich, J. (2004, June 15). HIV Infection Behind Bars. Clinical Infectious Diseases, 381, 1761=1763. 3. Brown, E. J., & Hook, M. V. (2006, September 1). 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