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Published in the Clarion,
1997, 4(1):2-4.
Social Determinants Related to the Risk of HIV Infection
and Progression to AIDS
Steffanie Strathdee, PhD
The following is an abridged version of a verbatim presentation
made to the House of Commons' Subcommittee on AIDS, on November
5, 1996. The focus of the session was to discuss social, political
and environmental influences that relate to the risk of HIV infection
and progression to AIDS. This session also represented a critical
opportunity to remind the members of parliament that the National
AIDS Strategy must be renewed if HIV research in Canada is to
continue.
These study findings highlight not only my own research but that
of several of my Canadian colleagues from the BC Centre for Excellence
in HIV/AIDS and the University of British Columbia: Drs. Robert
Hogg, Julio Montaner, Michael O'Shaughnessy and Martin Schechter;
Drs Michael Rekart and David Patrick from the the BC Centre for
Disease Control; and Marianna Ofner and Dr. Chris Archibald from
the Laboratory Centre for Disease Control HIV/AIDS Epidemiology
Division, Health Canada.
This research involves three different studies which were developed
in partnership with our local community partners and AIDS service
organizations, representing a total of almost 2000 study participants.
Each study was partly funded by Health Canada. Without this funding,
these critical studies bridging HIV/AIDS epidemiology and the
social sciences could not have been undertaken.
In the first decade of the HIV epidemic, researchers focused on
sexual and drug using behaviours which directly relate to the
risk of HIV infection. Now that we are well into the second decade,
our attentions have turned to the reasons for these behaviours
which represent avenues for change. Although there are a number
of social factors which influence health, I will only discuss
a few highlights. I will describe how poverty, unstable housing
and a history of sexual abuse have created communities of vulnerable
and marginalized people who take more risks and are in turn more
likely to become infected with HIV.
The high-risk populations which have been the focus of these studies
include homosexual and bisexual men, especially young gay men,
injection drug users, and those who are doubly affected because
of multiple risks, such as individuals who are injection drug
users and also gay or non-white, or women who are injection drug
users and are also involved in the sex trade. Although there are
clearly other communities which are at risk for HIV/AIDS in Canada,
such as Aboriginal persons and those of other ethnocultural communities,
less information is available on factors influencing risk behaviours
in these communities.
I will now discuss results from three studies in British Columbia
which have shed light on the relationship between social determinants
and the risk of developing HIV/AIDS.
These are:
- the Vancouver Lymphadenopathy AIDS
Study (VLAS), the largest and longest running AIDS study in Canada
involving 1000 gay men;
- the Vanguard Project, which began in
1995 as an extension of the VLAS-- its objective is to monitor
HIV incidence and risk behaviours in young gay men who are most
at risk of HIV infection, and like young people in general, may
feel invincible to real health threats such as HIV;
- The Point Project, a study conducted
in 1995 to identify factors related to a recent and ongoing outbreak
of HIV infection among Vancouver's injection drug using community.
One of the most important findings of the VLAS, published in the
esteemed medical journal, The Lancet, is the following:
- HIV-positive gay men with incomes
less than the poverty level were twice as likely to die within
a 10 year period relative to gay men with higher incomes.
Since Canada has a universal health care
system and medical care was provided equally to all our participants,
our finding could not be explained by factors such as access to
care. This study was the first to demonstrate that socio-economic
status plays a critical role in determining the health consequence
of HIV-infection.
Through studies such as the VLAS, it has been shown that older
gay men have adopted safer sexual behaviours as a result of the
HIV epidemic. However, this is not the case for young gay men,
such as those who have participated in the Vanguard Project. The
latter study has shown that:
- Over half of young gay men reported
having at least one episode of unprotected anal sex within the
last year; 47% with a regular partner and 25% with a casual partner.
In an attempt to uncover why so many
young gay men have unsafe sex despite high levels of awareness
about HIV/AIDS, we studied "risk-takers" and found the
following:
- Young gay men with less than a high
school education were nearly twice as likely to be risk-takers;
- Young gay men with a history of
sexual abuse were twice as likely to be risk-takers.
This finding supports the role of socio-economic
status and abuse in creating a climate of vulnerability. That
the consequences of sexual abuse are far-reaching, attests to
the personal and professional experience of others such as Arn
Schilder, who was chiefly responsible for the inclusion of such
questions in our study. Similar findings about the role of sexual
abuse and subsequent HIV risk behaviours have been reported in
San Francisco, Boston, and London suggesting that a history of
sexual abuse is one of the many missing pieces of the puzzle that
may help to account for the inability to adopt or negotiate safer
sex practices.
Striking similarities arose as a result of a study of HIV and
injection drug users in Canada's poorest neighbourhood, the Downtown
Eastside of Vancouver. This study revealed that:
- Injection drug users with unstable
housing conditions were twice as likely to become infected with
HIV.
We also studied why injection drug users
continue to share needles in a city which is home to North America's
largest needle exchange, which was highly rated in an independent
report by the U.S Centres for Disease Control in Atlanta. The
following themes emerged from the Point Project :
- Male injection drug users who were
homosexual/bisexual were 3 times more likely to share needles;
- Male and female injection drug users
with a history of sexual abuse were 3 times more likely to share
needles.
- Female injection drug users with
more symptoms of depression or who reported living with a drug
user were more likely to share needles.
In the face of an explosive outbreak
of HIV infection among injection drug users in Vancouver, we are
currently monitoring HIV infection rates and risk behaviours among
1000 injection drug users to further examine these issues.
Taken together, these results suggest that:
- social determinants influence both
the risk of HIV infection, and the speed with which HIV infection
will advance to full-blown AIDS.
Since fully one third of the young gay
men and the male injection drug users in our studies reported
having been sexually abused in addition to three quarters of the
female drug users, our findings suggest that:
- sexual abuse counselling should
be integrated into HIV prevention efforts.
Our finding that unstable housing increases
the likelihood of transmission suggests that:
- improving the living conditions
for persons at risk for HIV/AIDS can have a direct effect on
levels of risk.
This research shows how social factors
such as poverty, unstable housing and a history of sexual abuse
create layers of vulnerability which influence sexual and drug
using behaviours. Society creates these social determinants, and
has both an opportunity and a responsibility to change them. In
present day situations where there is discrimination, stigma and
a lack of will to create a climate for social change and empowerment,
diseases like HIV/AIDS will continue to flourish and will continue
to cost taxpayers billions of dollars. The country awaits the
federal government to provide the necessary leadership, without
which this epidemic will continue.
As you can see from this discussion, the research that many of
my colleagues and I conduct across Canada can directly lead to
reduced incidence and spread of this disease. Taxpayers can expect
to save $100,000 in direct medical costs for each HIV infection
that is prevented. If we prevent 1000 people from becoming infected
per year, or just 3 infections per day across this country, the
federal and provincial governments can save $100 million in future
medical costs that can go toward reducing the debt.
Sadly, in the absence of a renewed commitment to the National
AIDS Strategy, such research will effectively come to a halt after
March 1998. In the absence of a renewed federal commitment, the
research projects my colleagues and I work on all across Canada
will grind to a halt. Meanwhile, the US congress has just approved
a 7% increase in US AIDS research funds including $2.1
billion per year to the National Institutes of Health,
and more than $5 hundred million to the Centers for Disease
Control. Not renewing the National AIDS strategy is a national
tragedy. If our research is followed by appropriate action, perhaps
someday we won't need a National AIDS Strategy. Until that time,
the future of HIV prevention, treatment and care depends on it.
For more information, contact:
Bonnie Devlin
Vanguard Project Coordinator
608 - 1081 Burrard Street
Vancouver, BC, Canada, V6Z 1Y6
Tel: (604)806-8306
Fax: (604)806-9044
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