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HIV/AIDS & HCV
Written by J. FERNANDEZ   

Poverty and HIV/AIDS
J. FERNANDEZ
ALCOHOL/DRUG WORKER
THE ACUTE ASSESSMENT UNIT
THE MAUDSLEY HOSPITAL
(LONDON) UK

INTRODUCTION

POVERTY:

Firstly I will come to a universal definition of poverty and its implication/association with HIV. I will cover this from a global perspective and then relate this to urban areas and high risk groups.

Globally, the HIV pandemic has affected regional areas differently. The rates or forms of HIV transmission are arguably said to differ according to geography. In the more developed socio/economic countries, HIV transmission has occurred mainly between 'men who have sex with men', bisexuals and people who use street drugs intravenously. (Lewis/Dor) In the lower socio-economically developed countries, HIV transmission is usually through heterosexuals, with women being the most at risk, and mother to child transmission being high.

1. ECONOMIC RESOURCE MANAGEMENT/HEALTH RESOURCE FUNDING.

Africa, Asia and Latin America are arguably depleted of resources generally and therefore have fewer for the provision of comprehensive health care. International debt increased due to unfavoruable economic events of the 1970's. In the 1980's debt in Latin America and Sub-Sahara Africa, particularly had become so large countries where not able to service their debt. As the debts increased for many developing countries, so the option of default increased. In response to this the World Bank together with the IMF introduced a programme called Structural Adjustment. This enabled developing countries to borrow money from funds via the World Bank, despite the huge natinal debt, and borrowing levels, money was given under certain conditions. Structural Adjustment Programmes focussed to control inflation, control interest rates and money flow, and prune public spending whilst building upon an economic policy of comparative advantage. For many developing countries this led to fewer resources gained through public expenditure cuts to fund uniform comprehensive health provision, which had vast implications for health funding.

These countries also have high unemployment levels which means the majority of people live in poverty. Many of these people participate in informal sector activities, such as prostitution and intravenous drug-use, which has implications for HIV. Government resources are very scarcely spread, with the cost of medically testing HIV/AIDS within the community and in hospital is high and very much beyond providing universal care. In terms of health prevention, training local personnel and providing safer sex tools, such as condoms, may also be impossible to supply universally due to the high cost. HIV being contracted through blood can also expose inadequate screening and testing facilities in developing countries, where screening for the virus is often not done due no equipment in which to store and save blood, i.e. refrigerators and facilities for the 'blot' test.

2. THE VOLUNTARY SECTOR.

Essential services are provided mainly through the voluntary sector, such as Oxfam and Christian Aid, for example. These voluntary agencies are important in initiating policies and helping governments to provide essential resources. If these were not present there would be little to negligible health care provision. HIV/AIDS in these countries, being mainly transmitted through heterosexuals, affects the young potential earners of a country (Panos). This can deplete a countries future resources and taxpayers and lead to a viscous circle of an increasing demand on a scarce health resource funded from a constantly shrinking tax base. Ultimately, depleting developing countries financial resources, exposing its' poorly researched health care facilities and its inability to control epidemics, such as HIV/AIDS.

Without adequate resources there is very little lee-way for governments and local authorities to research the spread of HIV/AIDS regionally, in order to identify 'high risk' groups. This, in effect, prevents the most cost effective provision of scarce resources to areas where prevention would be the most efficient.

The voluntary sector struggles to provide some primary/emergency health cover, which tries to intiate community responsibility through its programmes.

3. COMPARISON IN A GLOBAL CONTEXT.

In the developed world, mostly countries in Europe and America have developed universal systems of health care. These systems are supported by a comparatively wellresourced tax base and research and development into transmission of HIV/AIDS is regularly financed. The planning of health care/prevention can be achieved on broad data to target high risk social groups with preventive measures.

Globally compared the lower developing countries have a higher rate of HIV contraction. A WHO press release in 1994 estimated the number of AIDS cases had globally increased by 60%. Geographically, the region which contributed most to these statistics were Sub-Sahara Africa, which is an area of large international debt and poor health resources. The highest growing area was South-East Asia where the number of cases had increased from 30,000 to 250,000. These areas are economically deprived when compared to others globally and have difficulty in providing adequately resources health services and preventive measures. The main countries with increasing HIV/AIDS figures are countries in South-East Asia and central Africa. These countries are classed as developing countries (World Development Report, 1995) and are more prevalent to high national debt, low tax revenues and poorly funded resources and sometimes restrcitive Structural Adjustment Programmes. Globally, when nation states are compared HIV/AIDS can be argued to reflect poverty i.e. poor resources, lack of funds and inadequate primary health care resources (AIDS Letter, 1994).

4 GLOBAL CONTEXT

In the regions of Africa and notably Asia the main groups affected with HIV are the heterosexual population and intravenous drug-users. This mainly affects heterosexual groups and women are the most vulnerable and at risk. However, within this region are the largest number of cases when compared worldwide. In mainly Eastern Europe and the Pacific, the groups mainly affected with HIV are the heterosexual groups and the male homosexual population although at a lower rate than in Africa and Asia. Globally, it appears that the lower economically developed countries are more prevalent to HIV transmission, highlighting a socio-economic dimension to the spread of the disease.

" There is evidence to suggest that the consequences of underdevelopment, such as poverty, underfunded health care systems and rural/urban migration may exert a profound influence on the distribution and spread of AIDS." ( Panos 1990.)

5. INDIVIDUAL POVERTY IN DEVELOPING COUNTRIES.

Poverty, also has implications on increasing risk behaviour in relation to HIV/AlDS transmission. Arguably poverty leads to migration from often rural areas to urban areas. This is an effect of industrialization, which many developing countries need to pass through on the road to industrialization.( Economics of Development.)

The people migrate to the urban centres, are often low-skilled, farm labourers, who often cannot find formal work in industrial cities, many people in this predicament often restore to informal sector work i.e. prostitution, and dealing/selling drugs. These activities are seen as' high risk' in terms of HIV/AlDS contraction. Prostitution due to the use of high risk sexual practices such as unprotected preventative sex, and in drug use the sharing of needles. In lesser developed countries, especially in South East Asia, these factors of people trying to escape poverty through prostitution and drugs is high. This as mentioned, increases the risk of HIV contraction, and coupled with the limited existence of health care resources even at primary levels for the teaching of preventative measures, leads to HIV contraction in these areas having a very high incidence. There is insufficient measures to provide curative measures as well as preventative measures to educate the local population against risk behaviour and changing sexual practices to reduce the spread of HIV.

Urban areas in lower developing countries, mainly in Africa, Sub-Sahara Africa and South East Asia have poorly resourced preventative measures. Prostitution in cities is high, safer sexual practises low, increasing risk to HIV contraction also intravenous drug-use is "also on the rise. This could arguably be to people pursuing informal sector activities in order to escape poverty and unemployment.

6. COMPARISON, GLOBALLY.

Comparing the urban situation to cities in the developed world, creates a different context and more complicated picture. However it can be argued poverty is becoming an increasingly central factor. A study in Montreal showed that the most at risk where people who were unemployed, a large majority being women active in the sex trade, from ethnic minorities. In the developed world ethnic minorities are more likely to be unemployed due to being invited to a country to perform unskilled manual work in periods of high economic activity i.e. factory labour, domestic work. In an economic down turn they are more likely to be laid-off and unemployed, and therefore prone to poverty. Since the world recession, in the early 1990's and the introduction of technology replacing many of the jobs these people held, unemployment has become a long-term phenonomen. Adapting to this for ethnic minorities in particular has involved informal sector activity mainly high risk activities in view to HIV.( Women and HIV/AIDS: Marge Berer/Sunanda Ray.)

In certain urban areas women are more at risk due to biological factors and through working in the sex industry. For, during sex a larger area of the mucosal is exposed increasing the risk of HIV contraction( Pratt.). As argued by Ray/ Berer, women who are low skilled, unemployed, dependent on welfare in many cases, drug dependent are more likely to turn to prostitution to survive economically and socially, increasing their contraction of HIV.

" There are more women infected in countries where the rate of infection is high among IDU's.......... AIDS is aid to be the biggest killer of women in New York City." (Women at risk of HIV/AIDS, Unsafe behaviour amongst women: Illicit injecting drug-use in Perth: National Centre for Research into the Prevention of drug-use 1991.)

In Perth the women from this survey practised 'high' risk activities, and prostitution was seen as the only effective way of funding a drug habit rather than formal work.

7. ECONOMIC MIGRATION

Also at risk are drug-users, dealers and young men and women who moved from areas of high unemployment to areas deemed to have greater job opportunities. i. e. moving from Liverpool to London. They often find work hard to find, become unemployed and dependent upon the welfare state. The lack of formal work and having no money, can often lead to homelessness, with the inability to finance accommodation. In this often desperate situation working in the informal sector in the sex trade, often practising high risk behaviour is seen as one way of getting money. However working in prostitution can lead to an increase in the contraction of STD's and notably HIV. The people in urban areas in developed countries, similar to those in the under developed countries, who are most at risk, in terms of HIV contraction are namely the unemployed, low-skilled and prone to poverty, and can lack access to health care. In the developed world they will tend to be women, young adults and from ethnic minorities. The factor of poverty and unemployment creates a common factor here. Partipipating in 'high risk' activities in the informal sector of work is a global phenonomen. Migration of people from rural areas, from areas of poverty to the major industrial cities globally often leads to the inability of the mass of these people to find work, therefore prone to unemployed and more attracted informal sectors of work, which increases their risk of HIV contraction. Poverty arguably drives people into informal areas of work such as prostitution, dealing and selling drugs, and often negligible safer sex use. People in poverty in urban areas are more at risk to HIV contraction due to these re-actions to poverty. In the developed world with an adequate levels of resources in which to identity high risk groups enables a cost effective and efficient targeting of resources at these groups, through research. In the developed countries this approach is not a possibility due to a severe lack of resources. Poor preventative measures leads to high risk groups being neglected and HIV contraction being high, in these areas.

Poverty hopefully has been shown to be a major factor in increasing HIV contraction. It leads on a micro level to individuals participating in ;high risk' activities to escape homelessness and poverty.

8. CONTRIBUTING FACTORS TO THE GLOBAL PANDEMIC

There are other factors influential upon the HIV pandemic such as the increase in global travel, and the improvement of transport technology, has enabled people to become more mobile. This has implications for HIV in that people who are infected can travel to and from their countries having unprotected sex, or participating in IV drug use and sharing needles, increasing the risk of HIV contraction for a number of people, globally. Global sex tourism also incresases the risk of people contracting HIV, as often in these activities safer sex is not practised.

Also the phenonomen of economic migration from areas of poverty to developed mature economies has implications in reference to HIV contraction. As has already been mentioned, migration from urban areas to developing countries has implications for HIV contraction. Studies in Montreal have shown that those most at risk are people prone to poverty and working in'high risk' forms of activity in the informal sector. These people tend to be ethnic minorities originally from developing countries. In London, a recent study at The Griffin Project ( Earls Court.) showed that the majority of people seeking HIV care are from different ethnic backgrounds, being migrants from mainly Spain, Italy and Ireland, migrants initially looking for employment and to increase their standards of living. ( The Griffin Statistics 19951996.) These migrants often turn to informal 'high risk' activities due to not finding work, becoming unemployed, in some cases not qualifying for benefit, or basic state provision, as a way of getting some money.

9. WHITE MIDDLE CLASS/POOR ETHNIC MINORITIES.

In the developing world HIV, especially in Britain is still seen as a homosexual male phenonomen. 70% of all known HIV cases in Britain are from people who define themselves as homosexual males. The emphasis of HIV preventative health education is mainly aimed at this social group. ( The Guardian April 1996.) However, globally the virus is more predominant in heterosexuals and injecting drug users. The increased level of economic migration and international travel could convert the disease from being acknowledged initially as a white, middle class homosexual male disease to a heterosexual one which reflects poverty, ethnicity, low skills, unemployment and high informal activity. In Northern America what was seen as a middle class white disease, is now already overshadowed by an increasing number of African-Americans and members of the Latino community, often the poorest communities in Northern America. Similar to the developing countries, the main route of transmission has been injecting drug use and heterosexual sexual activities.

" In the United States the 1980's image of people with AIDS as middle-class white homosexual men is already being overshadowed by its 1990's counterpart ..... underprivileged members of the black and Latino communities." ( Panos. 1990)

CONCLUSION

As has been argued, globally in urban areas poverty is a major factor for high risk informal activity, as this increases the chance of HIV contraction. The factor of migration being to escape economic hardship from developing countries to the developed can also have vast implications in the spread and contraction of HIV. In capital cities, and urban areas, the majority of HIV positive cases, who are heterosexual are from ethnic minorities prone to poverty, and engaging in 'high risk; informal activity is increasing. The main route of transmission for HIV tends to be either through unprotected penetrative sex, or sharing needles when injecting crack, heroin or amphetamines.

Services need to recognise that poverty, as is arguably the case in most communicable diseases, is a major factor increasing HIV contraction. This is the same for HIV, and as resources in the developing world are scarce, people prone to poverty in urban areas, are people who need the most urgent targeting. This is also the case in the developing world and resources need to be made available to aid these countries, trying to come to grips with this epidemic as this can have vast global complications, due to increased international travel and economic migration. A global targetting health stragety, considering poverty as an increasingly central factor could lead to lower levels of HIV contraction in high risk groups.This would also enable authorities to produce cost-effective preventative measures aimed at those most at risk.. Poverty in no uncertain terms needs to recognised. HIV needs to be tackled globally and poverty needs to be acknowledged as a major factor, which increases the distribution of HIV beyond the realms of the nation state.

1. Poverty is arguably an increasing factor in the spread of HIV contraction, already prevalent in the developing world, but increasing in the developed countries of America and Europe.

At present, the HIV pandemic has affected areas differently. The rates of HIV transmission differ according to global geography. The main rates of transmission are during heterosexual unprotected peneratative sex, and injecting drug-use, via the sharing of needles, this is the picture globally.

In developed countries, the main groups affected with HIV are still male homosexual men. However, in Europe and America the virus seems to be affecting many ethnic populations, usually the most economically disadvantaged groups in their respective regions.

2. There are differences in the provision of health care globally, which is based upon the relative affluence of a country and its ability to generate revenue via taxation. This in turn can be used to fund resources for health care facilities, and the countries of Europe and America are in a more prominent position as apposed to the developing countries which have large international debt problems, and high unemployment levels and therefore a very low tax base. Structural Adjustment Programmes can also have a vast influence on health care funding, which in developing countries is poorly resouced and inadqueate.

3. Globally compared the lower developing countries have a higher rate of HIV contraction. A WHO press release in 1994 estimated the number of AIDS cases had globally increased by 60% (WHO,1994). Geographically, the region which contributed most to these statistics were Sub-Sahara Africa, which is an area of large international debt and poor health resources. The highest growing area was South-East Asia where the number of cases had increased from 30,000 to 250,000. These areas are economically deprived when compared to others globally and have difficulty in providing adequately resources health services and preventive measures. The main countries with increasing HIV/AIDS figures are countries in South-East Asia and central Africa. These countries are classed as developing countries (World Development Report,1995) and are more prevalent to high national debt, low tax revenues and poorly funded resources in most cases under strict rules od the Structural Adjustment Programmes. Globally, when nation states are compared, HIV/AH)S can be argued to reflect socio-economic differences i.e. poor resources, lack of funds and inadequate primary health care resources (AIDS Letter,1994).

4. Individual sexual activity has implications for HIV transmission, in its re action to poverty. Faced with unemployment, dependency upon welfare and in most cases globally there is no welfare state, drives people into poverty and in order to survive, resort to informal sector activity such as prostitution which is 'high risk' in view to HIV contraction. Also people faced with this situation often partake in the dealing, experimenting and selling of drugs which has complications for HIV transmission.

5. In the developed countries the main high growth areas in HIV contraction are women, mainly from ethnic background , working in the sex industry, homeless and living in poverty.

In certain urban areas women are more at risk. As argued by Ray/ Berer, women who are low skilled, unemployed, dependent on welfare in many cases, drug dependent are more likely to turn to prostitution in order to survive economically and socially, increasing their contraction of HIV.

6. Migration also has implications for HIV contraction, as people move from areas of high unemployment to areas thought to have more job opportunities. In the developing world these usually entails a movement of people from rural areas to cities and in the developed world from depressed areas such as Liverpool to London. These economic migrants often find work hard to find, thus these migrants become unemployed and dependent upon the welfare state. The lack of formal work and having no money can often lead to homelessness with the inability to finance accommodation. In this often desperate situation working in the informal sector in the sex trade, often practising high risk behaviour is seen as one way of getting money. However, working in prostitution can lead to an increase in the contraction of STD's, notably HIV.

7. There are other factors influential upon the HIV pandemic such as the increase in global travel, and the improvement of transport technology, has enabled people to become more mobile. This has implications for HIV in that people who are infected can travel to and from their countries having unprotected sex, or participating in IV drug use and sharing needles, increasing the risk of HIV contraction for a number of people, globally. Also the phenonomen of economic migration from areas of poverty to developed mature economies has implications in reference to HIV contraction. In London, a recent study at The Griffin Project

Earls Court, showed that the majority of people seeking HIV care are from different ethnic backgrounds, being migrants from mainly Spain, Italy and Ireland, migrants initially looking for employment and to increase their standards of living. ( The Griffin Statistics 1995-1996.) These migrants often turn to informal 'high risk' activities due to not finding work, becoming unemployed, in some cases not qualifying for benefit, or basic state provision, as a way of getting some money.

8. In the developing world HIV, especially in Britain is still seen as a homosexual male phenonomen. 70% of all known HIV cases in Britain are from people who define themselves as homosexual gay males. The emphasis of HIV preventative health education is mainly aimed at this social group. ( The Guardian April 1996.) However, globally the virus is more predominant in heterosexuals and injecting drug users. The increased level of economic migration and international travel could convert the disease from being acknowledged initially as a white, middle class homosexual male disease to a heterosexual one which reflects poverty, ethnicity, low skills, unemployment and high informal activity. In America what was seen as a middle class white disease, is now already overshadowed by an increasing number of African-Americans and members of the Latino community, often the poorest communities in America. Similar to the developing countries, the main route of transmission has been injecting drug use and heterosexual sexual activities.

9. Services need to recognise that poverty, as is arguably the case in most communicable diseases, is a major factor increasing HIV contraction. This is the same for HIV, and as resources in the developing world are scarce, people prone to poverty in urban areas, are people who need the most urgent targeting . This is also the case in the developing world and resources need to be made available to aid these countries, trying to come to grips with this epidemic as this can have vast global complications, due to increased international travel and economic migration.

Structural Adjustment policies ought to consider the implications cuts in public spending can have for developing counturies to fund adqueate health resources increasing its inabilty to reduce an epidemic such as HIV/AIDS

This approach could lead to lower levels of HIV contraction in high risk groups, and enable authorities cost-effectiveness in preventative measures. Poverty in no uncertain terms needs to recognised. HIV needs to be tackled globally and poverty needs to be acknowledged as a major factor, which increases the distribution of HIV beyond the nation state.

BIBLIOGRAPHY

Berer M   1991    Women and HIV/AIDS PUBLISHER

Hamilton KA   1994    Global HIV/AIDS, A Strategy for US Leadership CSIS Working Group on Global HIV/AIDS

Lewis MA, Kenney G Dor A, Dighe R ,1989    AIDS in Developing Countries University Press of America

Mihill C   1996   Re-gaying of AIDS The Guardian 18 July

Panos D   1988    AIDS in the Third World The Norwegian Red Cross

Panos D   1990    AIDS The Third Epidemic The Norwegian Red Cross

Pratt R   1995    HIV/AIDS A Strategy for Nursing Care Macmillan

Phillips DR, Vershasselt Y 1994    Health and Development Routledge

WHO Press Release   1994   60% increase in AIDS estimated cases worldwide The AIDS Letter, No44, Aug/Sept

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