By the end of 2008, there were 33.4 million people living with HIV/AIDS, 5.2 percent of which live in Sub-Saharan Africa; less than half a percent of them live in North America and Western Europe (UNAIDS 2009, November). It is alarming that young people account for 40 percent of new HIV infections. Apart from health policies and education in each country, which is based on a political and religious ideology, it is certain that socio-economic status affects the spread of HIV/AIDS. Socio-economic status (SES) is a concept that includes income, education, and occupational status; and partly race, sex, and marital status. The structure that causes gaps in SES creates “social injustice”, the condition which may lead to poorer nutrition; greater exposure to unsafe water; increased contact with infectious disease agents; increased exposure to occupational and environmental hazards; increased complications of chronic diseases; increased alcohol, tobacco, and drug abuse; decreased social support; increased physiological and immunological vulnerability to disease; less access to comprehensive diagnostic, therapeutic, and rehabilitative services; lower quality of health care; less access to clinical preventive services, such as screening and counseling; and less access to community-based preventive measures (Levy & Sidel 2006: 10). Poor people in the inner cities are facing detrimental environmental conditions, such as lead paints and air pollution, crime, and violence (Schneider 2006: 232–233). They have poorer nutrition, less access to medical care and more psychological stress, which may lead to binge drinking, drug addiction, smoking, domestic violence, sexually transmitted infections (STI), etc. Poor people in the rural areas or poor countries also face environmental hazards and malnutrition. Recent research findings show that multiple factors contribute to the spread of HIV/AIDS in Africa: malnutrition, Malaria, Filariasis and Geohelminthes, and Schistosomiasis. Eileen Stillwaggon (2009: 2–3) reports that malnutrition is associated with the increase of HIV viral load and viral shedding. That increases HIV transmission sexually and at birth. She also explains that Malaria increases the HIV viral load 10 times as much and thereby increases the transmission rate. Lymphatic filariasis and soil-transmitted helminthes have been found to suppress immune response in HIV-negative people and increase viral load in people living with HIV, and thereby increase the HIV transmission. Schistosomiasis has been known to act as a co-factor of HIV transmission as well as do STIs. In addition Stillwagon (2009: 12) states that domestic violence and inheritance practices, as well as mundane risks of being exposed to contaminated waters and soils, affect the susceptibility to HIV.
HIV/AIDS accounted for 3.7 percent of female deaths in the world. HIV/AIDS was one of the leading causes of death among women aged 15 to 44, in low-income and middle income countries in 2004, according to the World Health Organization in its first study on women’s health (WHO 2009: 56). HIV/AIDS affects more women in low-income than in middle-income countries as the percentage of female deaths was 6.1 and 2.4 respectively in 2004 (WHO 2009: 25). HIV/AIDS ranked fifth as the cause of female death in low-income countries but ranked seventh in middle-income countries (WHO 2009: 25). The explanation Gupta, Parkhurst, Ogden et al. (2008: 765) give points at the environmental, structural and super-structural level of each country. To elaborate, the first level concerns the economic dependency on men that drive poor women to trade sex. The second level deals with laws that restrict women’s ownership of economic assets and the third level is related to gender inequality. Gender inequality manifests itself in different forms in different cultures. With regards to HIV/AIDS, lack of power to negotiate for safer sex, subject to sexploitation, subject to domestic violence, lack of social support, and lack of laws to protect women’s rights are part of the super-structural problems.
Not only poor countries suffer from HIV/AIDS, the US also faces a rising number of new HIV infections. In 2008 The New York Times reported that, based on new technology that generates more precise estimates, the correct number of people with new HIV infection status in 2006 was 56,300, which exceeded the old estimate of 40,000 by 40 per cent (The New York Times, 3 September 2008). According to the Centers for Disease Control (CDC) statistics, the ratio of American male: female who contracted HIV is about 3: 1, as male-to-male sexual contact is the major cause of infection (CDC 2010 a). New infections are found primarily among African Americans who most frequently contracted HIV via heterosexual intercourse (Harris 2008: A 15). The number of new cases of HIV among African Americans aged 13 to 29 per 100,000 Americans is about 55 compared with 10 Hispanic and 2 white Americans (The New York Times, 3 September 2008: A 22). African Americans accounted for almost half (46 percent) of people diagnosed with HIV in 37 states and 5 US dependent areas in 2007 (CDC 2010 b) while there are only 13 percent of African Americans in the entire country. It is noticeable that the US, which provides aid assistance to developing countries through the President’s Emergency Plan for AIDS Relief (PEPFAR) program, is facing a problem of unequal development within it’s own country. The underlying causes of this unequal development in a rich nation such as the US are the complex nature of its socio-economic and political system.
It is known that Christian values, such as Abstinence and Be faithful, play a crucial role in the US HIV Prevention Policy, especially during the George W. Bush administration. Wilson (2000: 252–253) reveals three different policies to teach sexuality education as a result of a 1999 survey of public school district superintendents in the US: 14 percent of the surveyed schools offered a comprehensive policy (where abstinence is an option); 51 percent had an abstinence-plus policy (where abstinence is the preferred option, but contraception is discussed as an effective means of HIV and teen pregnancy prevention); and 35 percent had an abstinence-only policy (where abstinence is the only option and discussion of contraception is allowed only if it is to stress its negative effects).
Although abstinence is being taught at schools as part of a comprehensive program since the 2000s, the US has the highest rates of teen pregnancy and births in the western industrialized world (Family First Aid 2010). This fact indicates that attention should be focused on other socio-cultural and political factors. It is known that poverty together with institutionalized discrimination among ethnic minorities in the US, such as African Americans and Latinos, is marginalizing them from the caucasian or white Americans.
Social class and racial issues hinder effective prevention policies. Waterston (1997: 1382) reported that some African American leaders think that needle-exchange programs designed to reduce HIV infection among intravenous drug users (IDUs) represent another case of whites “dumping on” and dismissing blacks. Also, as a result of the US public health policy, which does not provide universal governmental health insurance like that in West-European countries, Waterston (1997: 1389) noted that the poor, working poor and working class are faced with the stigma of “you can only blame yourself.” As a consequence, the Health Belief Model, which emphasizes the self efficacy of an individual, has been promoted as the viable strategy for American HIV prevention. Based on reviews conducted so far, the Health Belief Model, Social Cognitive Theory, and Theory of Planned Behavior remain the all time favorites since 1986 (Glanz, Rimer & Viswanath 2008: 32). The Health Belief Model was developed in 1958 by American Social Psychologists, Hochbaum and Rosenstock (Champion & Skinner 2008: 46). Albert Bandura, a Canadian-born psychologist who worked at Stanford University, formulated the Social Cognitive Theory in 1977 (McAlister, Perry & Parcel 2008: 170). Azjen, an American social psychologist, and his colleagues created the theory of Planned Behavior in 1991 (Montano & Kasprzyk 2008: 71). Health Education, together with Diffusion of Innovations (DOI) and Social Marketing, are considered the most important communication strategies to behavior change up to date. These American theories and ideology have been promoted and introduced in many developing countries through the PEPFAR program. For instance, a review of research done in the area of HIV/AIDS in Thailand by Thai researchers Pimpawun, Pencharn and Sansanee (1998: 10) concluded that before 1991 more research was biomedical in nature. After 1991, there has been more Social Science-based research done, emphasizing the change in the knowledge, attitude and behavior of an individual through behavior change communication (BCC).
Currently the United States Agency for International Development (USAID) proposes the Comprehensive Prevention Package shown in Table 1.
Dr. Aphichat Chamratrithirong (2009: 18–19) stated during the 12th National AIDS Conference in Thailand in 2009 that continuation of interventions according to the above-mentioned American model has proven to be effective for increasing condom use of men who have sex with men (MSM) with non-paying partners under the Coverage Plus project in 2005 and 2007; reducing sharing needles among IDUs of the Care and Support for Injecting Drug Users (CASIDU) Project of the Raksthai Foundation; and increasing condom use with regular clients among male cross-border migrants. However, it was harder to improve on knowledge of HIV/AIDS among youth and the attitudes towards People Living With HIV/Aids (PLWHA) of adolescents in a decaying neighbourhood. The most important point is that the access to health care services for female sex workers has affected condom use and consequently changed their behavior. Dr. Aphichat pointed out that, as the Health Belief Model works only up to a certain level, there are still more limitations due to structural problems.
As mentioned earlier, many scholars consider the American perspective on HIV prevention as too microscopic to solve the entire problem. The critics of this approach state firmly that the Health Belief Model, which is one of the top-three favourite models used in Public Health and Health Education, will not work in isolation; there must be structural (including enforcement) and environmental change to support an individual’s self efficacy.
To support this claim, Ainsworth, Beyerer and Soucat (2003: 15) explain how Thailand restructured its own HIV/AIDS policy in the 1990s and successfully reduced new infections from more than hundred thousand to about ten thousand a year in a decade. At that time Thailand, under the leadership of P.M. Anand Panyarachun, moved the AIDS policy from the responsibility of the Ministry of Public Health to the Office of the Prime Minister, with a multi-sectoral Prevention and Control Committee chaired by the P.M. himself. Next, the government launched a massive public information campaign under the leadership of Cabinet member, Mr. Mechai Viravaidya, the so-called Condom King. Third, in parallel, the ‘100% Condom Use Program’ was adopted nationwide to promote the mandatory use of condoms in commercial sex. Finally, the government repealed many repressive policies such as the reporting of names and addresses of AIDS patients and the prohibition of migration for PLWHA.
Continued via the link below:
The Localization of HIV/AIDS in Thailand