Surveillance, Social Risk, and Symbolism: Framing the Analysis for Research and Policy:

Social risk, stigma and space: key concepts for understanding HIV vulnerability among black men who have sex with men in New York City

Black men who have sex with men in the USA face disproportionate incidence rates of HIV. This paper presents findings from an ethnographic study conducted in New York City that explored the structural and socio-cultural factors shaping men's sexual relationships with the goal of furthering understandings of their HIV-related vulnerability. Methods included participant observation and in-depth interviews with 31 Black men who have sex with men (three times each) and 17 key informants. We found that HIV vulnerability is perceived as produced through structural inequalities including economic insecurity, housing instability, and stigma and discrimination. The theoretical concepts of social risk, intersectional stigma, and the social production of space are offered as lenses through which to analyse how structural inequalities shape HIV vulnerability. We found that social risk shaped HIV vulnerability by influencing men's decisions in four domains: 1) where to find sexual partners, 2) where to engage in sexual relationships, 3) what kinds of relationships to seek, and 4) whether to carry and to use condoms. Advancing conceptualisations of social risk, we show that intersectional stigma and the social production of space are key processes through which social risk generates HIV vulnerability among Black men who have sex with men.

Individual Factors of Social Acceptance in Patients Infected With Human Immunodeficiency Virus (HIV) at the Yazd Behavioral Consultation Center in Iran

Background:

A considerable number of patients infected with HIV also have mental health problems. Individual psychotherapy is an effective way to treat these issues. Lack of social acceptance is a barrier to patients receiving proper medication and emotional/psychological support.

Objectives:

The purpose of this study was to examine the individual factors of social acceptance in patients infected with human immunodeficiency virus.

Patients and Methods:

Fifty HIV-infected patients who were registered in the Behavioral Consultation Center entered the study. Each of them filled out a questionnaire based on the Crown-Marlow social acceptance scale. Their answers were evaluated according to the questionnaire key.

Results:

Forty-five patients (90%) were male and five (10%) were female. Their ages ranged between 28 and 52 years old. Other variables researched in this study include patients’ age, sex, education, occupation, place of living, marital status, family history of HIV, and family history of psychological disorders. Employed patients experienced more social acceptance than housewives and people who were unemployed or retired.

Conclusions:

This study showed that HIV-infected patients with jobs enjoy a great deal of acceptance from the people around them and a higher quality of life in general. It also led to suggestions for further study with the purpose of finding more effective solutions for HIV prevention and better strategies for dealing with psychological disorders. Such research could also help in providing an enhanced understanding of the potential psychological impact that AIDS has on patients in Iran.

Shifting the paradigm: using HIV surveillance data as a foundation for improving HIV care and preventing HIV infection

CONTEXT

Reducing HIV incidence in the United States and improving health outcomes for people living with HIV hinge on improving access to highly effective treatment and overcoming barriers to continuous treatment. Using laboratory tests routinely reported for HIV surveillance to monitor individuals' receipt of HIV care and contacting them to facilitate optimal care could help achieve these objectives. Historically, surveillance-based public health intervention with individuals for HIV control has been controversial because of concerns that risks to privacy and autonomy could outweigh benefits. But with the availability of lifesaving, transmission-interrupting treatment for HIV infection, some health departments have begun surveillance-based outreach to facilitate HIV medical care.

METHODS

Guided by ethics frameworks, we explored the ethical arguments for changing the uses of HIV surveillance data. To identify ethical, procedural, and strategic considerations, we reviewed the activities of health departments that are using HIV surveillance data to contact persons identified as needing assistance with initiating or returning to care.

FINDINGS

Although privacy concerns surrounding the uses of HIV surveillance data still exist, there are ethical concerns associated with not using HIV surveillance to maximize the benefits from HIV medical care and treatment. Early efforts to use surveillance data to facilitate optimal HIV medical care illustrate how the ethical burdens may vary depending on the local context and the specifics of implementation. Health departments laid the foundation for these activities by engaging stakeholders to gain their trust in sharing sensitive information; establishing or strengthening legal, policy and governance infrastructure; and developing communication and follow-up protocols that protect privacy.

CONCLUSIONS

We describe a shift toward using HIV surveillance to facilitate optimal HIV care. Health departments should review the considerations outlined before implementing new uses of HIV surveillance data, and they should commit to an ongoing review of activities with the objective of balancing beneficence, respect for persons, and justice.

Enabling and sustaining the activities of lay health influencers: lessons from a community-based tobacco cessation intervention study

The authors present findings from a community-based tobacco cessation project that trained lay health influencers to conduct brief interventions. They outline four major lessons regarding sustainability. First, participants were concerned about the impact that promoting cessation might have on social relationships. "Social risk" must be addressed during training to ensure long-term sustainability. Second, formal training provided participants with an increased sense of self-efficacy, allowed them to embrace a health influencer identity, and aided in further reducing social risk. Third, material resources functioned to mediate social tensions during health intervention conversations. A variety of resources should be made available to health influencers to accommodate type of relationship, timing, and location of the interaction. Finally, project design must be attentive to the creation of a "community of practice" among health influencers as an integral part of project sustainability. These lessons have broad implications for successful health promotion beyond tobacco cessation.

Comparative stigma of HIV/AIDS, SARS, and tuberculosis in Hong Kong

This study compares public stigma towards three types of infectious diseases— human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), severe acute respiratory syndrome (SARS), and tuberculosis (TB)—tests an attribution model of stigma, and explores the relationships between stigma and public attitudes towards government policies in Hong Kong. Using a population-based telephone survey, 3011 Hong Kong Chinese adults were randomly assigned to one of the three disease conditions and were interviewed about their attitudes and beliefs towards the assigned disease. Findings showed that public stigma was the highest towards HIV/AIDS, followed by TB and SARS. Using multi-sample model structural equation modeling, we found that the attributions of controllability, personal responsibility, and blame were applicable in explaining stigma across three disease types. Knowledge about the disease had no significant effect on stigma. Participants with less stigmatizing views had significantly more favorable attitudes towards government policies related to the diseases. The study is an important attempt in understanding the attributional mechanisms of stigma towards infectious diseases. Implications for stigma reduction and promotion of public awareness and disease prevention are discussed.

Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness

Data from a 1999 national telephone survey with a probability sample of English-speaking US adults (N=1,335) were used to assess how support for HIV surveillance policies is related to AIDS stigma and negative attitudes toward groups disproportionately affected by the epidemic. Anonymous reporting of HIV results to the government was supported by a margin of approximately 2-to-l, but name-based reporting was opposed 3-to-l. Compared with other respondents, supporters of name-based surveillance expressed significantly more negative feelings toward people with AIDS, gay men, lesbians, and injecting drug users. More than one third of all respondents reported that concerns about AIDS stigma would affect their own decision to be tested for HIV in the future. Implications for understanding the social construction of illness and for implementing effective HIV surveillance programs are discussed.

Perceived oral health status, unmet needs, and barriers to dental care among HIV/AIDS patients in a North Carolina cohort: impacts of race

OBJECTIVE

This prospective observational study examined differences in perceived oral health status, treatment needs, dental care utilization patterns, and barriers to care between HIV-infected non-Hispanic blacks and whites in North Carolina.

METHODS

632 adult HIV-infected medical clinic attendees provided information on their oral health status and dental care history during face-to-face interviews with a trained interviewer.

RESULTS

Compared to whites, blacks were significantly more likely to be female, older, less educated, have lower income, and have acquired HIV by heterosexual sex or injecting drug use. Although two-thirds of patients reported good oral health, blacks were significantly more likely to have loose teeth, need extractions, and be episodic dental care utilizers. Primary barriers to dental care were cost (30%), fear (19%), and low motivation (13%). Sixty-five percent of patients had unmet dental needs in the last three years. Race, cost, fear, and immune competence were significantly associated with unmet dental need in a multivariable model.

CONCLUSIONS

Disparities exist within this HIV-infected population in oral symptoms, utilization patterns, and perceived unmet dental need. Targeted interventions that address barriers to care are needed to help establish preventive dental care patterns in this region, especially among blacks.

HIV-related stigma and knowledge in the United States: prevalence and trends, 1991-1999

OBJECTIVES

This study assessed the prevalence of AIDS stigma and misinformation about HIV transmission in 1997 and 1999 and examined trends in stigma in the United States during the 1990s.

METHODS

Telephone surveys with national probability samples of English-speaking adults were conducted in the period 1996 to 1997 (n = 1309) and in 1998 to 1999 (n = 669). Findings were compared with results from a similar 1991 survey.

RESULTS

Overt expressions of stigma declined throughout the 1990s, with support for its most extreme and coercive forms (e.g., quarantine) at very low levels by 1999. However, inaccurate beliefs about the risks posed by casual social contact increased, as did the belief that people with AIDS (PWAs) deserve their illness. In 1999, approximately one third of respondents expressed discomfort and negative feelings toward PWAs.

CONCLUSION

Although support for extremely punitive policies toward PWAs has declined, AIDS remains a stigmatized condition in the United States. The persistence of discomfort with PWAs, blame directed at PWAs for their condition, and misapprehensions about casual social contact are cause for continuing concern and should be addressed in HIV prevention and education programs.

Evaluating the impact of criminal laws on HIV risk behavior

Criminal law is one of the regulatory tools being used in the United States to influence risk behavior by people who have HIV/AIDS. Several different types of laws have been or could be used in this way These include:

Disease stigma in U.S. public health law

Stigma has become an important concept in public health law. It is widely accepted that certain diseases are disfavored in society, leading to discrimination against people identified with them, which in turn has the tendency to drive an epidemic underground—i.e., to make it more difficult for voluntary public health programs to reach and succeed among populations bent on concealing their disease or risk status. The need to reduce stigma and its effects has been used to justify the passage of privacy and antidiscrimination law to protect people with HIV. More recently, stigma has been part of the arsenal of justification for special genetic antidiscrimination and privacy law. Despite its importance, however, there is no single widely accepted definition of stigma in social science, and its relationship to law has been generally under-theorized and unsupported by data, reducing our ability to effectively deploy law and other tools in the anti-stigma cause.

Public health law reform

Public health law reform is necessary because existing statutes are outdated, contain multiple layers of regulation, and are inconsistent. A model law would define the mission and functions of public health agen cies, provide a full range of flexible powers, specify clear criteria and procedures for activities, and provide protections for privacy and against discrimination. The law reform process provides an opportunity for public health agencies to draw attention to their resource needs and achievements and to form ties with constituency groups and enduring relations with the legislative branch of government. Ultimately, the law should become a catalyst, rather than an impediment, to reinvigorating the public health system.