Marginalisation and HIV/AIDS Notes

Introduction

  • Marginalisation, stigma, and HIV/AIDS are interconnected issues.
  • The lecture will cover global prevalence and case studies from Cambodia and Malawi.
  • Thesis: The epidemiology of HIV/AIDS is affected by cultural and structural factors; local context matters for effective interventions; stigma is a major barrier.
  • A coordinated response beyond stigma, focusing on human rights, is crucial.

HIV/AIDS

  • HIV (Human Immuno-deficiency Virus) attacks the human immune system.
  • AIDS (Acquired Immuno-deficiency Syndrome) occurs when the immune system is severely compromised, leading to opportunistic infections.
  • Transmission:
    • Sexual intercourse
    • Blood (transfusions, needles, syringes)
    • Mother-to-child
  • Testing: Blood test (most accurate) or rapid test (pin prick or oral fluid).
  • Primary treatment: Antiretroviral medication (ART).
  • Viral load: Measures how well medication is working.
  • Prophylaxis: PrEP and PEP.
  • Higher risks:
    • Biological: STIs, blood disorders, health problems in pregnant women.
    • Behavioural: Lack of condom use, sharing needles.

Epidemiology of HIV

  • In 2023:
    • 39.9 million people living with HIV.
      • 53% are women and children.
      • 1.4 million are children (0-14 years).
    • 1.3 million newly infected.
    • 630,000 lives lost due to AIDS-related causes.
  • People most affected:
    • 9.2% higher among transgender people.
    • 7.7% higher amongst gay men and MSM.
    • 5% higher among people who inject drugs.
    • 3% higher among sex workers.
    • 2.3% higher among young women and girls in eastern and southern Africa.
    • 1.3% higher among people in prisons.
  • Over 86 million people globally have contracted HIV since first detected in the 1980s.

Global Trends and Targets

  • Fast-track targets for HIV (95-95-95):
    • Initially 90-90-90 targets were set for 2020.
      • 90% of people living with HIV (PLWHIV) know their HIV status.
      • 90% of PLWHIV who know their HIV-positive status are accessing treatment.
      • 90% of PLWHIV on treatment have suppressed viral loads.
    • In 2023:
      • 86% of estimated PLWHIV were aware of their HIV status.
      • Of them, 89% were accessing treatment.
      • Of them, 93% were virally suppressed.
    • Aim for fewer than 500,000 cases in 2020 and fewer than 200,000 in 2030.
    • New 2030 targets (95-95-95) set in 2020.

Populations at Risk

  • HIV/AIDS is distributed unequally, reflecting patterns of vulnerability, poverty, and marginalisation.
  • Numbers are still increasing in eastern Europe, central Asia, the Middle East, North Africa, and Latin America.
  • For the first time, the number of new HIV infections outside sub-Saharan Africa was greater than those within.

Stigma and Human Rights

  • People with HIV are likely to be stigmatised, often by assumptions of deviant behaviour.
  • In many countries, sex between men (MSM), sex work, and injecting drug use are criminalised.
  • Three layers of HIV-related stigma:
    • Self-stigma: self-blame, shame.
    • Perceived stigma: fear that disclosure = stigmatisation.
    • Enacted stigma: discrimination because of actual or perceived HIV status.
  • Cultural changes show increased reference to human rights.
  • Mann and Tarantola identified 4 phases in the history of the response to HIV:
    1. Danger to alert people about.
    2. Problem of individual behaviour.
    3. Societally contextualised behavioural issue.
    4. Human-rights-linked challenge.
  • Vulnerability to HIV/AIDS exists when individuals are unable to make decisions about their health with full freedom and information.
  • Partnerships between governments, NGOs, and the private sector are crucial to safeguard human rights and lessen vulnerability to HIV/AIDS.

Case Study 1: Sex Work in Cambodia

  • High rates of HIV among brothel-based sex workers (1990s – up to 42%).
  • Government implemented 100% condom use in early 2000.
  • HIV rate fell from peak of 3% (1997) to 0.5% in 2009, with access to ART made available with support of International AID agencies and NGOs.
  • 2010: The Kingdom of Cambodia won the MDG award for HIV/AIDS.
  • Legislative changes:
    • International donor funding declined in the early 2000s due to fear of associations between human trafficking and sex work.
    • Introduction of Law on Suppression on Human Trafficking and Exploitation (2008).
    • 2010: Village/commune safety policy – “cleaning the streets”.
  • Unintended consequences:
    • Government corruption and collusion – police demand bribes.
  • 2020 – 75,000 people living with HIV; New cases 1,100; Incidence: 0.1:1000 population.

Profile of Sex Workers in Cambodia

  • Often coerced into sex work due to few options to increase income and life chances.
  • Poor rural women and girls.
  • Girls trafficked from China or Vietnam.
  • Sex workers often bonded and remain in poverty.
  • Rarely protected by the law.
  • Often stigmatised (“unclean”), marginalised, and criminalised.
  • Stigma makes accessing health, legal, and social services difficult.

MARPs Community Partnership Initiative

  • Most at-risk populations (MARPS) – sex workers, men who have sex with men (MSM), and injecting drug users.
  • UNAIDS and National AIDS Authority, Provincial AIDS authorities, police, military, development partners, and NGOs, in 2010.
  • Aim: “Restore the enabling environment so as to allow the effective and smooth delivery of all forms of services to all MARPs”.
  • Program involves sensitising information to police, harm reduction training.
  • Pilot program training saw an increase amongst police in favour of harm reduction programs.

Case Study 2: HIV in Malawi

  • Malawi has one of the highest prevalence rates in the world: 2020 – 990,000 people living with HIV; New cases 21,000; Incidence: 2.6:1000.
  • In 2002 90-90-90 targets = 90%-88%-92%.
  • HIV is a risk factor for developing active TB in Malawi; in 2015-16, 47% of people living with HIV were diagnosed as TB positive.
  • At-risk groups:
    • Women – sexual violence.
    • Young people - one-third of all new cases in the 15-24-year age group, and two-thirds of this cohort are female.
    • Sex workers - sex work is criminalised – 55% living with HIV.
    • MSM 7% of cases – homosexuality is criminalised.
    • Children and orphans – many are unaware of their status.

Cultural and Structural Barriers - Malawi

  • Cultural factors:
    • Multiple and concurrent sexual partners, in (2015-16) – 13% of men had two or more partners – higher amongst married men.
    • Gender inequality – women marry young (15-19 years) and early age sexual intercourse (14% before age 15).
    • High rates of intimate partner violence.
  • Other barriers:
    • Lack of facilities in rural areas.
    • Lack of HIV testing services.
    • Sex workers and MSM face punishment by law.

Stigma and HIV in Malawi

  • Heterosexual men – extra-marital sexual partners – rarely use condoms with spouses.
  • Stigma leads to non-disclosure and treatment avoidance.
  • Impact of stigma: isolated, termination from employment, verbal and physical abuse.
  • Women (more than half HIV cases are women) often caring for men with HIV and low rates of condom use.
  • Stigma – both internalised (perceived stigma and experienced stigma) and associated with gender expectations on women to be pure.
  • Results in low rates of disclosure to health professionals and low adherence to antiretroviral medication regimes stress.
  • Perceived stigma, shame results in high rates of anxiety and depression, loneliness, and isolation.

Malawi: National HIV and AIDS Strategic Plan (2015-2020)

  • Free condoms (in 2017, 70 million male condoms provided, still low use in women engaging in high-risk sex).
  • HIV education.
  • HIV prevention to be included in life skills education in schools – barriers to reaching all students: poor quality of teaching, language issues.
  • Radio shows – healthy policy plus for young people, family planning.
  • Prevention of mother-to-child transmission – all women with HIV are offered ART for life.
  • Voluntary medical male circumcision – marginal increase (21% in 2010 to 27.8% in 2016).
  • PrEP – not widely available, except through clinical trials; government approach to PrEP is “cautious”.
  • ART: 78% of people living with HIV on ART in 2018 (more women at 77% compared with men at 61%) – includes men who are unaware of their HIV status.

Community Based Responses - Malawi

  • In 2015, Malawi piloted the HIV Diagnostic Assistant (HDA): community-based, nonprofessional health workers encourage others from their communities to test for HIV.
  • Their presence significantly increased the number of people testing for HIV and led to an increase in HIV diagnoses and STIs.
  • Of the 7.4 million people tested for HIV in the HIV HDA period, 2.6 million (34%) were attributable to the intervention.
  • The Coalition of Women Living with HIV and AIDS (COWLHA) was established in 2006 in collaboration with the People Living with HIV (PLHIV) sector.
  • United voice of women and girls living with HIV and AIDS.
  • Seeking to end AIDS in women and girls through accessible HIV and AIDS services and promotion of women and girls’ rights.

HIV Trends in Australia

  • 2022 – 28,870 people living with HIV.
  • 48% decline in the number of HIV notifications in 10 years.
  • Decline in notifications in 2020 affected by COVID and lower access to testing.
  • Prevalence is highest amongst gay and bisexual men.
  • At-risk groups include Aboriginal and Torres Strait Islanders and migrants.
  • Prevalence amongst sex workers and people who inject drugs is low.
  • The 95-95-95 targets are trending:
    • 93% of people living with HIV are aware of their status.
    • 95% are receiving treatment.
    • 98% of those on treatment have an undetectable viral load.

Stigma and Historical Response in Australia

  • From 1901, anti-homosexual laws existed in most Australian States and Territories, and men found guilty of homosexual acts were imprisoned.
  • Cases peaked in 1987 with 2,412 cases.
  • Initial approach by authorities – campaigns to alert the public provoked fear and pointed the finger at homosexual men and intravenous drug users.
  • By the late 1980s, the Australian Government and community groups at risk established key public health initiatives which resulted in a dramatic decline in the number of new infections.
  • Ongoing public health messages need to target new at-risk groups – including Indigenous populations and new migrants.

Implications for Health and Practice

  • Both marginalisation and stigma lead to higher health needs.
  • HIV/AIDS is more prevalent in low-income and/or marginalised groups.
  • Health professionals contribute to this disease burden when they stigmatise people with HIV/AIDS.
  • The social construction of HIV:
    • Culturally-informed ideas about ‘normal’, ‘difference’, ‘deviance’, ‘healthy’ and ‘unhealthy’, ‘clean’ and ‘dirty’, as well as about body function, use, presentation, modification, and treatment, have historically stigmatised HIV/AIDS and people living with HIV/AIDS, leading to poor health outcomes.
    • When HIV/AIDS is ‘reconstructed’ to include human rights and workplace safety, stigma is reduced.
  • Social organisation of health and social services and government action:
    • Health Professionals’ stigmatisation of patients leads to poor health outcomes. Training in critical and self-reflexive thinking reduces stigma in the health workforce. Critical and reflexive thinking leads to informed, aware professionals.
    • Health Promotion: Many HIV/AIDS campaigns use fear to change behaviour. This can cause stigma and decrease health services utilisation. Yet, without fear, people may not take HIV/AIDS seriously.
    • Health-related laws, policies, and policing: HIV/AIDS sits at the interface between various overlapping criminal sectors (human trafficking, drugs, smuggling, sex work). Interventions in one area affect the others.
    • Community: Community development and action leads to sustainable and effective HIV/AIDS programs.
    • Pharmaceuticals: Internationally and nationally, drug companies and governments determine how affordable and accessible are condoms, HIV testing, and antiretroviral treatment.
    • Government action: Governments have a strong role to play, particularly in terms of policies.
    • Research and evidence: Ongoing research is needed to inform our interventions so they are fully evidence-based.

Conclusion

  • The epidemiology of HIV/AIDS reflects global patterns of marginalisation, social inequality, and stigma.
  • Individuals and groups engaged in sex work live at the interface of several highly moralised, and often criminalised, industries including human trafficking, drug sales, and smuggling.
  • When stigma enters politics, the resulting legal, social, and health policies can further marginalise vulnerable populations, leading to a higher disease burden, as seen in Cambodia.
  • When governments work towards reducing stigma through partnership-building, legislation, and policy, new cases of HIV can be avoided.
  • A multisectoral response to HIV and other epidemics is needed to ensure people are no longer criminalised for who they are or who they love.
  • Successful pandemic responses must be rooted in human rights approaches to public health, be evidence-based, community-led, and fully funded.Watch the video: