Although HIV infection affects people from all ethnic groups, genders, ages, and income levels, some groups have been significantly affected by the AIDS epidemic. These groups include men who have sex with men, injecting drug users, people with hemophilia, infants and children, women, and people of color.
Men Who Have Sex with Men
American society has issues with homosexuality. Grief may not be validated when relationships are viewed through prejudice and considered unacceptable. An example of this may be the reaction of churches to those who are living with, or have families living with, AIDS. Many congregants report that they do not get the support they need from their church families because of the stigma attached to HIV, AIDS, and homosexuality. Self-esteem issues and psychological issues including depression, anxiety, diagnosed mental illness, and risk-taking behaviors may also complicate the lives of these men.
Injecting Drug Users
People who continue to use injecting drugs, despite warnings and information about risks, may be viewed by some as “deserving” their infection. Harm reduction measures such as needle exchange programs have been proven to reduce the transmission of bloodborne pathogens such as HIV, HBV, and HCV. In addition, poverty, self-esteem issues, and psychological issues (including depression, anxiety, diagnosed mental illness, and risk-taking behaviors) may also complicate the lives of injection drug users.
People with Hemophilia
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 contaminated blood products. There is anger within this community because evidence shows that the companies manufacturing 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 significant discrimination against them. The Ryan White Care Act, funding HIV services, and the Ricky Ray Act, which provides compensation to hemophiliacs infected with HIV, were both named after HIV-positive hemophiliacs who suffered significant discrimination (arson, refusal of admittance to grade school) in their hometowns.
Infants and Children
At the end of 2010, Florida ranked second, behind New York, in the number of cumulative pediatric AIDS cases reported (FDOH, 2010a). Ninety-five percent of pediatric AIDS cases were acquired perinatally—the remaining 5% were acquired through blood transfusion, hemophilia, or another risk. Prevention of perinatal HIV is a high priority in Florida and several initiatives are focused on that goal. There has been significant progress in combating perinatally acquired AIDS—its incidence has declined from a peak of 194 HIV-infected babies born in Florida in 1992 to 7 cases in 2012, although that is up from 3 cases in 2011 (FDOH, 2012).
Children show significant differences in their HIV disease progression and their virologic and immunologic responses when compared to adults. Without drug treatment, children may have developmental delay, P. carinii pneumonia, failure to thrive, recurrent bacterial infections, and other conditions related to HIV. The ARV treatments that are available for HIV infection may not be available in pediatric formulations. The medications may have different side effects in children than they do in adults.
It is vital that women know their HIV status before and during pregnancy. Antiretroviral treatment significantly reduces the chance that their child will become infected with HIV. Prior to the development of antiretroviral therapies, most HIV-infected children were very sick by 7 years of age. In 1994 scientists discovered that a short treatment course of the medication AZT for pregnant women dramatically reduced the number, and rate, of children who became infected perinatally. Cesarean sections for delivery may be warranted in certain cases to reduce HIV transmission. As a result, perinatal HIV infections have substantially declined in the developed world.
Early diagnosis of HIV infection in newborns is now possible. Antiretroviral therapy for infants is now the standard of care, and should be started as soon as the child is determined by testing to be HIV-infected. Apparently uninfected children born to HIV-positive mothers are currently treated with antiretroviral medicines for 6 weeks to reduce any possibility of HIV transmission.
Women in the United States, and worldwide, are becoming infected with HIV at higher rates than any other group of people. This is particularly true of women of color. Certain strains of HIV may infect women more easily. The strain of HIV present in Thailand seems to transmit more easily to women through sexual intercourse. Scientists believe that women and receptive partners are more easily infected with HIV than insertive partners. Receptive partners are at greater risk for transmission of any sexually transmitted disease, including HIV.
Women infected with HIV are at increased risk for a number of gynecologic problems, including pelvic inflammatory disease (PID), abscesses of the fallopian tubes and ovaries, and recurrent yeast infections. Some studies have found that HIV-infected women have a higher prevalence of infection with the human papilloma virus (HPV). Cervical dysplasia is a precancerous condition of the cervix caused by certain strains of HPV. Cervical dysplasia in HIV-infected women often becomes more aggressive as the woman’s immune system declines. This may lead to invasive cervical carcinoma, which is an AIDS-indicator condition. It is important for women with HIV to have more frequent Pap tests.
Women may become infected with HIV from a partner who either used injecting drugs or had other sexual partners. Many of these women assumed that the relationship was monogamous, or that they “knew” their partner’s history. Many others are unable to discuss or implement safer sex practices because they lack the skills or because domestic violence is present in their relationship.
Women who are infected with HIV, or who have family members who have HIV, face some unique challenges. Women may postpone taking medication, or going to medical appointments, in order to care for their children or other family members. Many women have problems with lack of transportation, lack of health insurance, limited education, and low income. They may have childcare problems that prevent them from going to medical appointments. Several studies have shown that women in the United States who have HIV receive fewer healthcare services and HIV medications than men. This may be because women aren’t diagnosed or tested as frequently.
Women (and also men) may fear disclosing their HIV status to others, fearing loss of their jobs, housing, or other forms of discrimination. Single parents with HIV may feel particularly fearful because of their lack of support.
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 (WSDOH, 2007).
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. African American and Hispanic women make up less than 25% of the total U.S. population, but account for 77% of all reported AIDS cases in women. African Americans make up about 12% of the population, but account for 37% of all AIDS cases in the United States. Hispanics make up about 13% of the population, but account for 20% of the AIDS cases in the United States. In some areas, disparities also exist in the number of AIDS cases in Native Americans.
There is no single reason that stands out as to why the disparities exist. One factor is health disparities, which are 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” for a variety of reasons. Thus, even when income is not a barrier, access to early intervention and treatment may be limited. And HIV may be only one of a list of problems that also includes adequate housing, food, and employment.
Another factor may be the diversities within these populations. Diversity is evident in immigrant status, religion, languages, and geographic locations, as well as socioeconomic conditions. Providing targeted information to these diverse populations is challenging.
A significant amount of denial about HIV risk continues to exist in these communities. As with other groups, there may also be fear and stigmatization of those who have HIV. Prevention messages must be tailored and presented in a culturally and linguistically appropriate manner. The messages must be carried through channels that are appropriate for the individual community. These channels may include religious institutions or respected elders in the community. Ironically, it may be these institutions or elders who, in the past, have contributed to the misinformation and stigma associated with HIV.
Many HIV prevention programs are recognizing the importance of working with diverse communities. Input from these communities must be included in planning, delivering, and evaluating HIV prevention activities.