Presentation to the House of Commons Sub-Committee on AIDS in Ottawa on November 5, 1996.

Social Determinants Related to HIV Infection 
and Progression to AIDS

Steffanie Strathdee, PhD.

Madame/Mister Chairman, good morning and thank you for extending this invitation to address the Committee.

In this brief presentation, I will 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.

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, funding without which these critical studies bridging HIV/AIDS epidemiology and the social sciences could not have been undertaken.

Social Determinants: Poverty, Housing, Stigma, Sexual Abuse.

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, researchers' attentions have turned to the antecedents of these behaviours which represent avenues for change. Although there are a number of social factors which influence health, today I will speak about only a few due to time constraints. 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.

High-Risk Populations: Homosexual/Bisexual Men, Injection Drug Users (IDUs), Mixed-Risk profiles.

The high risk populations I will focus on today 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 ethnocultural communities, less information is available on factors influencing risk behaviours in these groups. We may discuss these separately in the discussion period.

Epidemiologic Studies of HIV-affected Populations at the BC Centre for Excellence in HIV/AIDS: VLAS, Vanguard Project, Point Project

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:

1. the Vancouver Lymphadenopathy AIDS Study (VLAS), which since 1982 represents the largest and longest running study of 1000 gay men in Canada;
2. 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 like young people in general may feel invincible to real health threats such as HIV.
3. the Point Project, which was 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.
   

Summary of Results linking Social Determinants to Risk of HIV Infection and Progression to AIDS in Gay Men.

I will now summarize some of the findings of these 3 studies.

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

This study was the first to demonstrate that socio-economic status plays a critical role in determining the health consequence of HIV-infection, as is well documented for other conditions such as cancer and cardiovascular disease. 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.


Through studies such as the VLAS, it has been shown that 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. This 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.

Although these figures are alarming, they are not significantly different from those in the VLAS in the early 1980's; nor are they very different from those reported among young gay men in United States, the United Kingdom and The Netherlands.

In an attempt to uncover why so many young gay men have unsafe sex despite high levels of awareness about HIV/AIDS, we compared "risk takers" who had recently engaged in unprotected sex with a casual male partner to "non-risk takers" who consistently practiced safer sex. We found the following:

Young gay men with less than a high-school education were nearly twice as likely to be risk takers;

This finding supports the role of socio-economic status in creating a climate environment of vulnerability.

However, one of the more surprising findings was the following:

Young gay men with a history of sexual abuse were twice as likely to be risk takers.

This suggests that the consequences of sexual abuse are particularly far-reaching, which attests to the personal and professional experience of Mr. Arn Schilder, who was also 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 safer sex practices.

Summary of Results linking Social Determinants to Risk of HIV Infection and Progression to AIDS in Injection Drug Users

Striking similarities arose as a result of a study of HIV and injection drug users in Canada's poorest neighbourhood, the Downtown East side of Vancouver. This study revealed that:

Injection drug users with unstable housing conditions were twice as likely to become infected with HIV.

The Point Project also allowed for an analysis to determine why injection drug users continue to borrow needles in a city which is home to North America's largest and highly rated needle exchanges. After taking into account factors directly related to their drug use, the following themes emerged:

• 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.

Implications:

Taken together, these results suggest that social determinants influence both the risk of HIV infection, and directly influence an individual's risk of progression from HIV infection 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, 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.


Conclusions

These three studies demonstrate 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. These factors are further influenced by others such as race, gender, sexual orientation and age. The difference is that society creates these social determinants, and we have both an opportunity and a responsibility to change them.

In present day situations where there is discrimination, stigma and a lack of political will to create a climate for social change and empowerment, diseases like HIV/AIDS will continue to flourish. The country awaits the federal government to provide the necessary leadership, without which this epidemic will continue.

In the absence of a renewed committment to the National AIDS Strategy such research will effectively come to a halt after March, 1998. Thank you for your attention.