20 February 2012

HIV and AIDS

Introduction

HIV/AIDS is a global pandemic that affects individuals, families, and entire communities around the world and has profound social and economic implications. In 2004, the pandemic killed an estimated 3 million people, and an additional 40 million were living with the infection (1). The epidemic primarily affects the world’s poorest people in countries with the greatest gender inequities, disparities in income, and access to productive resources. HIV/AIDS is primarily a heterosexual epidemic in developing countries, yet sex between men remains a critical aspect of the epidemic in middle and high-income countries. (However an estimated one-third of new infections now occur by heterosexual contact in these countries) (2). Often caregivers, families, and friends encounter the same stigma and prejudice as those they care for endure. The everyday psychosocial issues for persons living with or affected by HIV/AIDS are compounded by poverty, homelessness, addictions, unsanitary living conditions, war and trauma, discrimination, and societal indifference.

The demographics behind HIV/AIDS are as diverse as the world in which we live and work, calling for a range of responses from the social work profession. The eradication of HIV/AIDS represents one of humanity’s greatest challenges, one that requires cooperation and comprehensive collaboration between scientific disciplines, governments, social institutions, the media, the social work and health care professions, and the general public.

Social workers, by virtue of their training, their commitment to human rights, and the fact that they are uniquely placed within a wide variety of health and welfare settings, can play a very effective role in the global effort to address the HIV/AIDS epidemic.

HIV/AIDS and globa trends

HIV transmission occurs through behaviors that pose a risk for exposure. Transmission is not limited to one particular race/ethnicity, gender, relationship or affiliation, or community membership. To date, the known HIV transmission modes are through the exchange of contaminated blood, semen and vaginal secretions, and breast milk (3).

Although research, education, prevention, treatment, and the delivery of services have improved since the advent of HIV and AIDS in the early 1980s, the incidence continues to rise around the world, with nearly 40 million people estimated to be living with HIV/AIDS (4). This disease has been documented in every part of the world, yet the overwhelming majority (95%) of people living with HIV/AIDS are in low to middle-income countries.

Trends show that nations in sub-Saharan Africa continue to the hardest hit, with two-thirds (66 %) of all people living with HIV in sub-Saharan Africa, and 77 % of all woment with HIV. Between 2.1. and 2.7 million people died of HIV-related illnesses in this region in 2005 alone, with another 2.8. to 3.0 million newly infected with HIV in that same year (5). In South Africa, it is believed that at least one adult in five is living with the virus. There is also a growing epidemic in Asia. As of 2004, an estimated 8.2 million people in Asia and the Pacific were infected with HIV/AIDS, and estimates show that in Eastern Europe and Central Asia combined, approximately 1.4 million people are living with the virus. Also, a number of the Caribbean island states are reported to have some of the worst epidemics compared with anywhere outside of sub-Saharan Africa. Latin America (including Central America) has an estimated 1.7 million people living with HIV/AIDS (6).

Each day, 8,000 people die of AIDS-related conditions, in part due to a lack of awareness of their health status and/or limited access to the antiretroviral therapies (ARTs) available to delay disease progression. In fact, a significant factor in the spread of this disease is that most people worldwide living with HIV/AIDS are not aware of their health status (7).

In Eastern Europe and Central Asia, HIV/AIDS is spread primarily by injection drug use (IDU) via the sharing of needles. However, in some areas there is documentation of increased heterosexual transmission. As a result, the Russian Federation is considered among the epidemic’s “next wave” of persons living with HIV/AIDS (8).

In the United States and Canada, about 25 percent of newly acquired HIV infections have been attributed to injecting drug use, whereas in Australia and Europe, IDU accounts for 10 percent of new HIV diagnoses. In many parts of the world, hepatitis is a critical co-occurring health concern due to shared modes of transmission through intravenous drug use and other activities that involve the exchange of blood. Additionally, the global incidence rate of tuberculosis (TB) is growing at approximately 0.4 percent annually with a much faster rate of growth in sub-Saharan Africa, as well as countries in the former Soviet Union (9). It is crucial to connect the issues of TB and HIV/AIDS, since not only has the HIV infection been associated with a rise in TB, but TB has been linked and associated with increased susceptibility to HIV (10).

Globally, the interconnection and affect of HIV/AIDS and TB on nations’ economic and social health, coupled with the increased incidence of malaria, led to the creation and multi-country funding of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Continued funding and commitment is needed to support this partnership.

HIV/AIDS and societal issuse

Family members, including those with HIV, are involved in many different roles, from parent to child to caregiver. As an international public health issue, HIV/AIDS is proving severely disruptive to families, entire communities, and social structures worldwide. AIDS affects the entire household, with family members losing their most productive years, resulting in permanent poverty as the illness reduces the ability to work, and increases medical costs, as well as funeral expenses. Young people continue to be at the growing center of the pandemic. For example, in Africa, nearly one million African students are deprived of a teacher annually because of the impact of HIV/AIDS (11). Worldwide, there is insufficient programming and support services for family members/caregivers and orphans. Children orphaned due to AIDS-related deaths of parents or caregivers face an unpredictable future that is often compounded by the same stigma, discrimination, and social isolation faced by their parents/caregivers (12).

Children infected and affected by AIDS will face similar problems to other children in difficult circumstances. It is estimated that by the year 2010 in sub-Saharan Africa alone, more than 18 million children – more than all the children in the United Kingdom – will have lost at least one parent to AIDS (13). The loss of parents can have profound emotional, economic, and developmental consequences for any child, especially in poor households. In Africa, AIDS has produced the phenomenon of child-headed households, where the older children have to care for their siblings in the absence of adults. This situation will be worse in cases where some of the children may also have HIV/AIDS and are in need of medical care. Child caregivers and other orphans in poor households may have to earn a living off the streets or in poorly paid work where they are even further at risk from hunger, disease, or sexual exploitation and consequent risk of HIV infection.

Stigma and discrimination are universally experienced by persons living with and affected by HIV/AIDS. Additionally, gender inequities in social and economic status, as well as lack of access to preventive services, education, and health care, increase women and girls’ vulnerability to HIV/AIDS. Females are increasingly at risk of HIV or AIDS; studies show young women are three times more vulnerable to HIV infection than their male counterparts (14). Women and young girls account for 57 percent of those in sub-Saharan Africa with the disease. Young women, who are often vulnerable as a result of having little or even no control over their own sexual activity, now make up more than 60 percent of those aged 15 to 24 infected worldwide (15). Studies in the United States documented several factors accounting for disproportionate HIV morbidity among women and girls, including racial/ethnic group affiliation, socioeconomic status, overall health, sexual risk-taking, and higher rates of sexually transmitted infections (STIs). Worldwide, unequal property and inheritance rights, lack of marital rights, and the use of “transactional sex” in exchange for food, shelter, or other basic necessities exacerbate women’s vulnerability. Sexual violence increases a woman’s risk for HIV, with data showing women who report early and chronic sexual abuse have a seven-fold increase in HIV-related risk behaviors and markers of risk, compared with women without abuse histories (8, 16).

Where there is poverty, health risks increase due to poor water supplies, inadequate food and shelter, and increased drug use and sex trade. As labor forces decline due to the affects of HIV/AIDS and co-occurring health and mental health problems, health needs increase within communities that already experience health disparities (17). The diagnosis of HIV, or the affiliation of living with a family member with HIV/AIDS, can elicit stigma and discrimination that can affect the health and mental health status of individuals, families, and entire communities. This may contribute to increased isolation and added health and mental health concerns, ranging from anxiety and depression to traumatic responses and substance abuse (18). Clearly, one’s vulnerability to HIV/AIDS exists within a broader context of poverty, seen in the lack of access to education, lack of economic opportunities, and the lack of, or inability to access health-related services.

Access to treatment

Although antiretroviral therapies (ART) have been available in some form for almost two decades, access to medications and necessary health care for people living with HIV and AIDS ranges from inconsistent to nonexistent for many of the populations affected by the disease. Research protocols continue to have limited access to ARTs, and HIV/AIDS clinical trials are not universally available. Additionally, of great concern is the growing number of people who do not know they are HIV positive. These people may be unaware of their HIV status for a variety of reasons, ranging from limited access to education about HIV/AIDS to uncertainty of where to get tested and find treatment for a positive diagnosis, to shame or fear of the stigma associated with HIV/AIDS.

For many parts of the world, access to medications and necessary care and treatment is limited to those with economic resources. For example, access to antiretroviral coverage by persons with HIV/AIDS living in low and middle-income countries ranges from a low of 5 percent (North Africa and Middle East) to a high of 62 percent (Caribbean and Latin America), with the mean at 15 percent (7).

Conversely, in countries with greater health resources, the emergence of ART, coupled with an increased access through private insurance and government-funded programs, has resulted in a positive, dramatic change for many people living with HIV/AIDS. For many in these countries, living with HIV or AIDS has transitioned to living with a lifelong, chronic illness, often with a renewed sense of hope and challenge. Yet in general, for those with access to medications, the complexities of a strict medication regimen cannot be sustained over extended periods of time; adherence is not as simple as taking medications. An increasing number of people living with AIDS (PLWA) are unable to tolerate the toxicity and/or severe side effects that are common with the medications (ART and prophylaxis treatments), while others experience unexpected health deterioration, or the drugs simply “fail the patient” (19). People living with HIV/AIDS frequently identify the need for additional behavioral health and social supports to help promote medication adherence (20).

The global community has responded through a number of worldwide initiatives. For example, the World Health Organization’s (WHO) Three by Five Initiative was launched in 2003 to ensure treatment for 3 million people living with HIV/AIDS in low and middle-income countries by the end of 2005. Yet the targeted treatment numbers have not been met consistently. Governments and pharmaceutical industries must be held accountable to ensure that people living with HIV/AIDS have access to all ART and related HIV medications, regardless of ability to pay for treatment and care (21).

Generic medications, utilizing approved formularies, must be universally available worldwide. Specific attention must be given to creating access to medications, including newly available one-a-day anti-retroviral treatments, to poorer nations where the need is greatest.

Social workers have long provided essential leadership, support, and participation in mobilizing responses to HIV/AIDS. Therefore, social workers, working in collaboration with allied health and mental health providers, should work towards building a continuum of care. This will involve services that address the specialized health, mental health, prevention, psychosocial support, and other related care and treatment interventions necessary to promote the well-being of the individual living with HIV or AIDS. The social work professional must work to ensure that HIV/AIDS issues are mainstreamed into development efforts, emphasizing awareness, prevention, and care and treatment as priority areas to be actively included in organizational systems and policies.

Social workers should enter into respectful professional partnerships with people living with HIV and AIDS, with due regard to basic social work values such as self-determination, dignity, and worth of the individual. From a broader global perspective, AIDS drains the human and institutional capacities that drive sustainable development. This, in turn, disrupts production and consumption, erodes productivity in public sectors, and ultimately diminishes national wealth. Policies must reflect the connection of the individual, the family, the community, and the economy. Partnerships with organizations or leaders need to be mindful of the particular political, social, economic, and cultural context that shapes that particular relationship (22).

Policy statement

IFSW recognizes that HIV/AIDS is a serious threat to the health and development of the world and that commitment to tackle the consequences is needed from every sector within society.

Building Partnerships

IFSW acknowledges that partnerships – global, national and local – are vital to tackle the epidemic. IFSW will:

• Give support to the global implementation of comprehensive anti-discriminatory policies for people affected by HIV/AIDS

• Support giving access to, and funding for, programs that provide the necessary psychosocial services and medications to hard-to-reach populations, including, but not limited to, sex workers, people using injecting drugs, and people and communities affected by economic or social instability or war-related conflict.

• Encourage the promotion of formal commitments of governments to advocate and defend the right to equitable treatment of all people, irrespective of culture and beliefs; regardless of gender, age, sexual orientation, race, religion, civil status, and affiliation; and route of HIV transmission, stage of disease progression, and level of treatment adherence.

• Encourage those promoting abstinence and marital fidelity as a means of preventing HIV/AIDS to actively address and take into account gender disparities and power differentials between men and women (28).

• Encourage multi-national and local businesses to develop policies and practices that promote prevention, treatment, and care for their employees, as well as to collaborate with other businesses and the government on such programs.

Education and Prevention

IFSW recognizes that education is a key strategy in tackling the epidemic. Consequently IFSW acknowledges that:
• Although initial education efforts have focused on safe-sex strategies, it has been shown that prevention efforts must begin at an early age and must be targeted, respect the unique needs of the populations at risk, and be accompanied by care, treatment, and support interventions (23, 24). Prevention efforts must include access to condoms.

• Countries with quality education, prevention, and care programs (including access to antiretroviral medications) often experience lower rates of infection with HIV (25). Education must target both providers and consumers of services.

• Social workers should support the development and implementation of programs that include educational and prevention strategies that meet the needs of diverse population segments of society. Access to formal education promotes economic sustainability and supports efforts to ensure that all children have academic and/or vocational education opportunities.

• Social workers should support science-based, comprehensive sexuality education programs for youth and adults that are culturally sensitive and promote culturally competent practice.

• Social workers should support adequate staffing of health care workers and the necessary infrastructures through enhanced government and private sector assistance to ensure training and continuing education targeting all health and mental health providers. These efforts must be based on research and practice knowledge that is best suited to meet the unique need of the local communities.

• Social work education should include curricula that address HIV/AIDS from the perspective of the profession’s core values (12, 26). Social workers have the responsibility to continuously update their knowledge about all aspects of HIV, including new prevention strategies, treatment and care models, medications, research, and policies.

Comprehensive Care and Treatment

IFSW supports access to affordable services that is based on a continuum of care for people infected and affected by HIV/AIDS. Due to the range of psychosocial and cultural issues that affect the health and mental health status of people living with and affected by HIV/AIDS, IFSW encourages efforts to:
.
• Advocate and lobby for more equitable and just distribution of resources, services and support structures worldwide, and in particular the provision of antiretroviral medications.

• Ensure that all people have access to mental health and behavioral health treatment/services regardless of ability to pay.

• Protect vulnerable children and youth by providing psychosocial support for children affected by HIV/AIDS (27).

• Encourage the implementation of Voluntary Counseling and Testing (VCT) services and ensuring that they are accessible and either free or affordable in resource-poor settings. Ensure access to the full range of substance use services, focusing on harm reduction models that include needle-exchange programs.

• Adopt affordable prevention, treatment, and care programs that are adapted to reach all people affected by HIV/AIDS, particularly those whose language, culture, or immigrant status might limit their access to services or subject them to oppressive and discriminatory situations.

• Develop strategic alliances with other partners and develop a multi-sectoral approach to tackling the epidemic.

Partnerships with People Affected by HIV/AIDS

IFSW supports the principle that people who are HIV-positive and those with AIDS are a vital resource for prevention, and they must be closely involved in any strategy used to tackle the epidemic. Consequently social workers must:

• Enter into respectful professional partnerships with people living with HIV/AIDS, with due regard to basic social work values such as self-determination, dignity, and worth of the individual.

• Work in partnership with people living with HIV/AIDS (PLWHAs) to develop programs that encourage openness, disclosure where appropriate, and the sharing of experiences of living with the virus.

• Identify, strengthen, and support the role of PLWHAs and the community response to the pandemic.

• Work with PLWHAs and their self-help organizations and networks and provide assistance where appropriate.

• Advocate for fair and adequate representation of non-governmental organizations (NGO’s) and the PLWHAs on the governance structure of the Global Fund to Fight AIDs, TB, and Malaria and related country coordinating committees.

Research

IFSW supports all research efforts that address health disparities, including the following:

• Ensure protocols that address the unique bio-medical needs of women, children, and adolescents, and the psychosocial and spiritual needs of all people affected by HIV/AIDS.

• Promote full funding for research that identifies effective primary and secondary prevention and educational strategies, service delivery models, and the impact of related policies. Research protocols must include people living with and affected by HIV/AIDS.

• Promote fully funded research, development, and distribution of microbicides and HIV/AIDS vaccines.

References

1) InterAction. (2005). AIDS: Overcoming the global epidemic. Monday Developments. Washington, DC: Author.

2) UNAIDS. (2005). AIDS epidemic update: Special report on HIV prevention [Online]. Retrieved from www.unaids.org

3) NASW. (2005). HIV/AIDS: A general overview. NASW HIV/AIDS Spectrum Project Fact Sheet [Online]. Retrieved from www.socialworkers.org/practice/hiv_aids/aidsday.asp

4) Joint United Nations Programme on HIV/AIDS (UNAIDS). (2004, December). AIDS epidemic update (Online). Retrieved from
www.unaids.org

5) UNAIDS. (2004, December). AIDS epidemic update [Online]. Retrieved from www.unaids.org

6) InterAction. (2005). AIDS: Overcoming the global epidemic. Monday Developments. Washington, DC: Author.

7) World Health Organization. (2005). Progress in global access to HIV anti-retroviral therapy: An update on 3 x 5 [Online]. Retrieved from
www.who.int/hiv/mediacentre/news57/en/index.html

8) Kaiser Family Foundation (KFF). (2005). The global HIV/AIDS epidemic: HIV/AIDS policy fact sheet. Menlo Park, CA: Author. Available at: www.kff.org

9) World Health Organization. (2003). Roll back malaria: Economic costs of malaria [Online]. Retrieved from
www.rollbackmalaria.org

10) Loewenson, R. & Whiteside, A. (1997). Social and economic issues of HIV/AIDS in Southern Africa [Online]. Retrieved from
www.iaen.org

11) Summers, T., Kates, J., & Murphy, G. (2002). The tip of the iceberg: The global impact of HIV/AIDS on youth [Online]. Retrieved from www.kff.org/hivaids/6043-index.cfm

12) National Association of Social Workers. (2003). Social work speaks. HIV/AIDS Policy Statement. Washington, DC: Author.

13) UNICEF. (2005). Fact sheets [Online]. Retrieved from
www.unicef.org/uniteforchildren/knowmore/knowmore_30104.htm

14) UNAIDS. (2004b). Women and AIDS: A growing challenge [Fact sheet]. UNAIDS Epidemic Update 2004 [Online]. Retrieved from
www.unaids.org

15) InterAction. (2005). AIDS: Overcoming the global epidemic. Monday Developments. Washington, DC: Author.

16) Wyatt, G., Myers, H., Williams, J., Ramirez Kitchen, C., Loeb, T., Carmona, J., Wyatt, L., Chin, D., & Presley, N. (2002). Does a history of trauma contribute to HIV risk for women of color: Implications for prevention and policy. American Journal of Public Health 92 (4), 660-665.

17) Kaplan, L., Tomaszewski, E., & Gorin, S. (2004). Current trends and the future of HIV/AIDS services: A social work perspective. Health and Social Work, 29 (2).

18) Ellenberg, L. W. (1998). HIV risk assessment in mental health settings. In D. Aronstein & B. Thompson (Eds.), HIV and social work: A practitioner’s guide (pp. 233–246). Binghamton, NY: Harrington Park Press.

19) Tomaszewski, E. (Ed.). (2001). Mental health and HIV/AIDS: Social work practice issues [Trainer Manual]. Washington, DC: National Association of Social Workers.

20) Gronningsaeter, A. (Ed.). 2004. Living conditions and quality of life among people living with HIV in Norway, Fafo Report 451.

21) World Bank. (2003). Considering HIV/AIDS in development assistance: A toolkit [Online]. Retrieved from www.worldbank.org/aids-econ/toolkit/intro.htm

22) .IFSW. (2000). Social work manifesto on HIV/AIDS [Online]. Retrieved from www.ifsw.org/en/p38000241.html

23) Centers for Disease Control and Prevention. (2001). Morbidity and mortality weekly report, 50, 429–433.

24) United States Agency for International Development (USAID). (2001). Leading the way: USAID responds to HIV/AIDS. Washington, DC: Author.

25) American Association for World Health (AAWH). (2001). World AIDS Day Resource Booklet, pp. 10-12. Washington, DC: Author. Available at: www.thebody.com/aawh/wad2001/trends.html

26) Hall. (2002). Social work training and deployment in selected eastern and southern African countries with regard to HIV/AIDS. Washington, DC: SAfAIDS, IFSW and UNAIDS.

27) SAfAIDS, UNAIDS, and IFSW. (2000). The role of the social welfare sector in Africa: Strengthening the capacities of vulnerable children and families in the context of HIV/AIDS. Harare, Zimbabwe: Compiled by Nigel Hall, Southern Africa AIDS Information Dissemination Service, June

28) Southern Africa AIDS action. (2001). Faith and Response to HIV. Southern Africa AIDS Information Dissemination Service, Issue 49, July – September

Prepared by National Association of Social Workers (USA)

Lead Author: Evelyn P. Tomaszewski, MSW, ACSW
Workgroup: Arne Gronningsaeter, Nigel Hall, Serge Paul, Melvin Wilson, and
Luisa López

Reviewers: AvenirSocial (Swiss Association of Professional Social Work). Canadian Association of Social Workers, Irish Association of Social Workers, National Association of Social Workers (USA), and IFSW Policy and Action Committee (John Ang)

Approved at IFSW General Meeting, Munich, Germany 2006

Policy withdrawn in year 2006