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Continuing Education for Health Professionals

KY: HIV/AIDS

Module 3

Groups Identified at Higher Risk for HIV

Identified risk groups are those groups of people that carry an increased risk of either becoming infected with HIV or, when infected, transmitting the virus to another person. In some cases, increased risk is the result of unsafe behaviors, while in other cases it is related to socioeconomic factors or other factors beyond the control of the individual or group.

The most important aspect of identifying groups at high risk for contracting HIV is how to structure support and prevention efforts. Public health officials and governments are most efficient in their efforts when they are able to identify groups that are most vulnerable to HIV infection. This is done with up-to-date information on the most likely sources of new infections as well as an understanding of epidemic patterns (WHO, 2012a).

The World Health Organization recommends a “mode of transmission” model to understand, at the local level, which subpopulations are most at risk of HIV infection and which risk behaviors may facilitate transmission. This information is used to develop national responses (WHO, 2012a). Using current epidemiologic and behavioral information, the proportion of the adult male and female population that belongs to each of several risk groups are precisely defined by each country. This includes:

  • Sex workers and their clients
  • Injecting drug users
  • Men who have sex with men
  • Individuals with multiple heterosexual sex partners in the last year
  • Spouses of individuals with higher-risk behavior
  • Individuals in stable heterosexual relationships (WHO, 2012a)

The mode of transmission model also looks at the prevalence of HIV infection and other sexually transmitted infections within each risk group. The average number of sexual or injecting partners per year and the average number of exposures per partner are considered, taking into account the average level of protective behavior (eg, condom use or use of clean needles), for individuals in each risk group. The probability of HIV transmission per exposure act in each risk group is determined, taking into account the effect of sexually transmitted infections and the prevalence of male circumcision (WHO, 2012a).

Mode of transmission groupings are reflected in public health figures in Kentucky and are used to analyze the effects of the HIV epidemic in the state. In Kentucky, as in other parts of the world, men who have sex with men account for the largest percentage of cumulative HIV cases, followed by injection drug users. Although representing a smaller percentage of cumulative cases, heterosexual transmission accounts for a significant percentage of cumulative HIV cases in Kentucky.

 

*Female Heterosexual = A female not reporting drug use, but reporting sex with males.
**“Other” includes persons with “transfusion/transplant” or “hemophilia/coagulation” listed as mode of transmission. Also includes persons with perinatal exposure but were diagnosed as an adult.
Note: Excludes 81 pediatric cases (<13 years).
Source: KCHFS, 2013.

 

Cumulative Adult/Adolescent HIV Cases by Transmission Route
(through June 30, 2013, Kentucky)

Transmission route

Number

Percent

Men who have sex with men (MSM)

4,794

54

Injection drug users (IDU)

942

11

MSM/IDU

444

5

Heterosexual

1,237

14

Femaleh*

269

3

Other**

118

1

Undetermined

1,019

12

Men Who Have Sex with Men

In Kentucky, as well as nationally, gay, bisexual, and other men who have sex with men (MSM) of all races and ethnicities remain the population most profoundly affected by HIV. In 2010 the estimated number of new HIV infections among MSM in the United States was 29,800, which is a 12% increase in the number of new infections among MSM since 2008 (CDC, 2013a).

Although MSM represent about 4% of the male population in the United States, in 2010 MSM accounted for 78% of new HIV infections among males and 63% of all new infections. MSM accounted for a little more than half of all people living with HIV infection in 2009. In 2010 white MSM continued to account for the largest number of new HIV infections, by transmission category, followed closely by black MSM. Since the epidemic began, an estimated 302,148 MSM with an AIDS diagnosis have died, including an estimated 5,909 in 2010 (CDC, 2013a).

Bisexual men—men who have sex with both men and women—face some of the same challenges as MSM. However, it has been more difficult to reach men who do not identify as being gay with HIV prevention efforts and activities. HIV-negative men who have sex with men may also be less diligent in their prevention efforts. As with any behavior change, people can become “tired” of safer sex messages, and may make choices that place them at risk. Some may feel that HIV infection is inevitable (although it is not) and purposely engage in unprotected sex.

Injecting Drug Users

Significant challenges persist in addressing HIV prevention among injecting drug users [IDUs]. Perhaps the greatest obstacles are country laws, policies, and regulations that criminalize drug use; the continued stigma associated with injecting drug use, addiction, and HIV; a lack of knowledge about the effectiveness of interventions that limit both unsafe injection practices and HIV transmission; and a failure among policymakers to grasp the human and public health consequences of failure to reach IDUs with effective treatment, care, and prevention services.

Center for Strategic and International Studies, 2010

Injecting drug use (IDU) is responsible for HIV infections in 10% of all cases worldwide. Injecting drug use is not only a risk factor for HIV transmission but it may also change the natural course of HIV infection. In addition, heroin and other opioids have immune-modulating effects that may alter the progression of HIV infection and susceptibility to infections (Meijerink et al., 2014).

Harm reduction measures such as syringe exchange programs have been proven to reduce the transmission of bloodborne pathogens like HIV and hepatitis. Although research has repeatedly shown that needle exchange programs are effective in curbing infection, these programs are controversial because some people believe that providing clean needles and a place to exchange used needles constitutes “approval” of injection drug use.

Poverty and self-esteem and psychological issues may complicate the lives of injecting drug users. The desire to stop using illegal drugs may not be matched with the ability to stop. The reality about inpatient treatment facilities is that, while there is a large demand for spaces, very few are available. Many substance abusers are placed on waiting lists when they want treatment, and by the time there is a place for them, they may be lost to followup.

People of Color

African Americans and Hispanics have disproportionately higher rates of AIDS in the United States, despite the fact that there are no biologic reasons for the disparities. There is no single reason why these disparities exist. One factor is inadequate healthcare linked to socioeconomic conditions. Another factor is distrust of the healthcare system. Both legacies of the past and current issues of race mean that many people of color do not trust “the system.” Thus, even when income is not a barrier, access to early intervention and treatment may be limited. Furthermore, HIV may be only one of a list of problems that also includes inadequate housing, food, and employment.

Another factor may be the diversities within these populations. Diversity is evident in immigrant status, religion, language, and geographic location, as well as socioeconomic conditions. Providing targeted information to these diverse populations is challenging.

Blacks/African Americans

Blacks/African Americans represent about 13% of the U.S. population but continue to experience the most severe burden of HIV, compared with other races and ethnicities. Since the epidemic began, more than a quarter of a million blacks with an AIDS diagnosis have died. Unless the course of the epidemic changes, at some point in their lifetime, an estimated 1 in 16 black men and 1 in 32 black women will be diagnosed with HIV infection (CDC, 2013a).

African American gay, bisexual, and other men who have sex with men represented an estimated 72% of new infections among all African American men and 36% of new HIV infections among all gay and bisexual men. More new HIV infections occurred among young African American gay and bisexual men than any other subgroup of gay and bisexual men. The rate of new HIV infection in African Americans is 8 times that of whites based on population size (CDC, 2014a).

In 2010 African American women accounted for 29% of the estimated new HIV infections among all adult and adolescent African Americans. Most new HIV infections among African American women are attributed to heterosexual contact. The estimated rate of new HIV infections for African American women was 20 times that of white women and almost 5 times that of Hispanic/Latino women (CDC, 2014a).

Hispanics/Latinos

Hispanics/Latinos represent nearly 17% of the population but accounted for 21% of new HIV infections in 2010. About 20% of people living with HIV infection in 2009 were Hispanics/Latinos. In 2010 the rate of new HIV infections for Latino males was 2.9 times that for white males, and the rate of new infections for Latinas was 4.2 times that for white females. Since the epidemic began, more than 96,200 Hispanics/Latinos with an AIDS diagnosis have died (CDC, 2013a).

Almost 80% of the HIV diagnoses among Hispanic/Latino men in the United States and dependent areas in 2011 were attributed to male-to-male sexual contact. Eighty-six percent of the HIV diagnoses among Hispanic/Latino women were attributed to heterosexual contact (CDC, 2014a).

American Indians and Alaska Natives

American Indians and Alaska Natives represent about 1.2% of the U.S. population or about 5.2 million people. Although American Indians and Alaska Natives represented less than 1% of new HIV infections in 2010, HIV is a critical public health issue. Compared with other races/ethnicities, American Indians and Alaska Natives have poorer survival rates after an HIV diagnosis and also face special HIV prevention challenges, including poverty and culturally based stigma. In 2011 men accounted for 76% and women accounted for 24% of the estimated 212 American Indians and Alaska Natives diagnosed with HIV infections (CDC, 2014a).

Asian Americans

Asian Americans make up about 5% of the U.S. population. Despite being a rapidly growing population in the United States, Asians have experienced stable numbers of new HIV infections in recent years. Overall, Asians continue to account for only a small proportion of new HIV infections in the United States and dependent areas (CDC, 2014a).

In 2010 Asians accounted for 2% of new HIV infections in the United States. Eighty-six percent of the estimated 821 HIV diagnoses among Asian men in the United States and dependent areas in 2011 were attributed to male-to-male sexual contact. Ninety-two percent of the estimated 153 HIV diagnoses among Asian women were attributed to heterosexual contact (CDC, 2014a).

Estimates of New HIV Infections in the United States
for the Most-Affected Subpopulations, 2010

chart: estimates of new HIV infections

Estimated HIV incidence among adults and adolescents in the United States, 2007–2010. HIV Surveillance Supplemental Report 2012;17(4). Subpopulations representing 2% or less of the overall U.S. epidemic are not reflected in this chart. Abbreviations: MSM, men who have sex with men; IDU, injection drug user. Source: CDC, 2012.

Women and HIV

Thirty years into the epidemic, women make up half of those living with HIV worldwide. In sub-Saharan Africa young women are as much as eight times more likely than men to be living with HIV (Hardee et al., 2014). In the United States and worldwide women are becoming infected with HIV at higher rates than any other group of people.

Women often become infected with HIV from a partner who has either used injecting drugs or has had other sexual partners. Prevention efforts can be ineffective because some women are unable to discuss or implement safer sex practices or because domestic violence is present in their relationship. Still others are forced into non-consensual sex and lack the power to refuse.

Women who are infected with HIV, or who have family members who have HIV, face unique challenges. They may postpone taking medication, or going to medical appointments, in order to care for their children or other family members. Women (as with men) may fear disclosing their HIV status to others, fearing loss of their jobs or housing, or other forms of discrimination.

Because of these issues, many women who are infected with HIV do not consider this to be their worst problem. Their symptoms may be mild and manageable for many years. Meanwhile, they may have more pressing concerns, such as their lack of income, housing, access to medical care, possible abusive relationships, and concerns about their children.

A number of strategies have been identified to empower women and reduce their vulnerability to HIV:

  • Promoting women’s employment, income, and livelihood opportunities
  • Transforming legal norms to empower women, including marriage, inheritance, and property rights
  • Providing universal education for girls
  • Enacting and enforcing laws against sexual violence, including intimate partner violence
  • Eradicating human trafficking
  • Developing HIV prevention methods that women can control
  • Transforming gender norms (Hardee et al., 2014)

People with Hemophilia

Hemophiliacs lack the ability to produce certain blood clotting factors. With the advent of anti-hemophilic factor concentrates (clotting material pooled out of donated blood plasma) hemophiliacs can receive injections of the clotting factors that they lack, which in turn allows them to lead relatively normal lives.

Unfortunately, because the raw materials for these concentrates came from donated blood, many hemophiliacs were infected with HIV prior to the advent of blood testing. During the 1980s, 90% of severe hemophiliacs contracted HIV or HCV through use of these products. There is anger within this community because there is evidence to show that the companies who manufactured the concentrates knew their products might be contaminated but continued to distribute them anyway.

Some people considered hemophiliacs to be innocent victims of HIV, but there has been discrimination against them. The Ryan White Care Act (funding HIV services) and the Ricky Ray Act (providing compensation to hemophiliacs infected with HIV) were both named for HIV-positive hemophiliacs who suffered significant discrimination (arson, refusal of admittance to grade school) in their home towns.

HIV-Infected Children

According to UNAIDS, there are 3.4 million children under the age of 15 and 2 million adolescents who are infected with HIV (Sohn & Hazra, 2013). The vast majority of these children were perinatally infected.

Effective pediatric HIV treatment involves early diagnosis, prompt initiation of antiretroviral therapy, and frequent monitoring to ensure quality care. Antiretroviral therapy initiation in the first 3 months of life can reduce mortality by 76%. Without antiretroviral therapy, 52% of perinatally HIV-infected infants and 26% of postnatally HIV-infected infants will die within 12 months (MMWR, 2014a).

In 2011 approximately 4500 HIV-infected children under the age of 15 lived in North America, the vast majority in the United States. Approximately two-thirds of perinatally HIV-infected adolescents in the United States are African-American/non-Hispanic, and approximately 20% are Hispanic; 53% are female. Given the low mortality and very low number of newly infected babies (<100 per year), the perinatally infected population in the United States is at a relatively stable number of over 10,000 individuals, most of whom are now young adults and with the oldest members now entering the fourth decade of life (Sohn & Hazra, 2013).

Depending on the setting, the pediatric HIV epidemic has entered or is entering the next phase of its evolution as children grow up and face new challenges of living with HIV. Perinatally HIV-infected adolescents are a highly unique patient sub-population, having been infected before development of their immune systems, been subject to suboptimal antiretroviral therapy options and formulations, and face transitioning from complete dependence on adult caregivers to becoming their own caregivers (Sohn & Hazra, 2013).

The evolution of HIV into a chronic disease has no greater impact than on the life of a child. Children that families, clinicians, and policymakers at one time expected to die are living into their twenties and having children of their own. Unanticipated issues such as reproductive health, higher education, and career training are now urgent needs (Sohn & Hazra, 2013).

Sex Workers

The HIV epidemic continues to have a profound effect on female, male, and transgender sex workers who engage in sexual activity for income, employment, or non-monetary items such as food, drugs, and shelter (CDC, 2013c). Globally, female sex workers are 14 times more likely to be infected with HIV than adult women overall (Wirtz et al., 2014).

HIV prevalence among sex workers varies across the world, from 22% in Eastern and Southern Africa and 17% in Western and Central Africa to less than 5% in all other regions. HIV prevalence among female sex workers may be as high as 37% in sub-Saharan Africa, 11% in Eastern Europe, and 6% in Latin America (UNAIDS, 2013a).

Exceptionally high HIV prevalence has been found among female sex workers in urban settings in some countries: 57% in Kisumu, Kenya; 32% in Mauritius; and 20% in Bangkok, Thailand (UNAIDS, 2013b).

Among sex workers, a number of factors work against the use of preventive measures. Social stigma, isolation, legal and issues, gender bias, higher payments for sex without condoms, forced sexual acts, and drug use combine to make sex workers vulnerable to sexually transmitted diseases such as HIV.

Although condom use is known to be highly effective in preventing the spread of HIV, many sex workers do not carry condoms due to fear of police harassment. To look more closely at this problem, Research conducted by Human Rights Watch in New York, Washington, DC, Los Angeles, and San Francisco found that police often seize condoms as evidence of prostitution-related offenses and introduce the condoms as evidence in criminal proceedings (Wurth et al., 2013).

Because of these police practices, some members of the groups most at risk of infection have stopped carrying condoms or carry only a few and sometimes engaged in sex without protection as a result. To address this issue, the U.S. Presidential Advisory Council on HIV/AIDS has adopted a resolution recognizing that the use of condom possession as evidence of prostitution-related offenses undermines HIV prevention and testing efforts. District attorneys in two jurisdictions—Nassau County, NY, and San Francisco—have stopped using condoms as evidence of prostitution and police in Washington, DC, are distributing know-your-rights cards clarifying that the Metropolitan Police Department cannot interfere with possession of condoms and providing information on how to file a complaint against an officer for harassing, stopping, or searching a person on the basis of carrying condoms (Wurth et al., 2013).

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