All is Not Well in the Southern Front: Southern Policies Fueling the Spread of HIV: Alex Wasserman
It is not uncommon for individuals to associate an expanding HIV/AIDS epidemic with less industrialized societies. As Americans, many take comfort in and typically assume that the epidemic is largely regulated. With a prevalent sense of individual responsibility and government policies to aid in treatment, this is an ostensibly reasonable assumption. This may be the case in certain concentrated areas within the country, but upon consideration of some additional figures and the broad social structures that shape them, one would quickly be shaken from any false sense of comfort. The figures being referenced are those that highlight the rapidly accelerating rate at which HIV/AIDS is becoming prevalent in the Southern United States (1). The focus of much recent research has been the disparity in both incidence and prevalence in the South as compared to other regions of the country (1). Being of primary source of concern for those within the areas of public policy, law and public health, a wide variety of factors have naturally been named attributable for this increasing gap.
A sufficient exploration of these forces far exceeds the scope of this paper, thus its focus will center on faulty public policies to explain why the current approach to HIV/AIDS prevention in the Southern United States is a cause for much concern. Additionally, after a review of the social and political conditions under which this epidemic is flourishing in the South, one might forego any former sense of ease or complacency and question why there is not a more permeating impression of duty, or even outrage. The primary aim of this paper will thus be to highlight ways in which the approach to HIV/AIDS prevention in the South have been largely unsuccessful in mitigating a burgeoning epidemic. This will be accomplished by examining the dire effects that lack of sex education have had within the nation’s southern states. It will also be instrumental to explore the policies, both at the state and federal level, that have aided in fueling the issue (1). It is critical to examine these policies because it is under this federal and state-level activity that ineffective educational models such as “Abstinence Only” models are permitted to continue. The failure to acknowledge the problem at a policy level will likely result in the same at the school level. Finally, an end goal of this paper will be to consider the South’s current conditions in an attempt to prompt alternative ideas in adopting new approaches to epidemic.
CONTEXT: HIV/AIDS AND THE SOUTH
An endemic disease, the risk of HIV/AIDS is often discounted in the United States. It’s prevalence, however, is much more pervasive than many perceive it to be, currently affecting more than 1.1 million Americans. Its incidence also need not be neglected at a rate of 56,000 new infections every year. These staggering figures become increasingly shocking as one explores the way in which they are distributed throughout the country. The Southern United States bears a disproportionate amount of the burden. Just over a third of the national population lives in this region; however, approximately half of Americans living with HIV/AIDS lives in the South. The same principle applies to minority exposure to the disease. African Americans make up just under a third of the population in several southern states; yet, they comprise nearly three-fourths of those with HIV in the region. Similar data is available on the prevalence among Latinos living in southern states (2).
Not only are individuals living in the South exhibiting more cases, but those living with HIV/AIDS in the South are significantly more likely to die of AIDS than those living in other regions of the country. To contextualize this disparity, it is useful to highlight the fact that the South is somewhat of a epidemiological anomaly. Typically, as the death rates of a disease remain steady, the prevalence diminishes (3). As a result of its spiking incidence rate, however, the region sticks out as an exception to the rule. The South currently has the highest rates of new infections, the highest AIDS-specific mortality rate, and the largest number of individuals living with HIV/AIDS (2).
These figures can be explained by a number of factors. The most prominent for the purposes of this paper, however, shall be the interplay between a lack of comprehensive sex education in southern schools and a slew of other counterproductive public policies. These policies have been instrumental in shaping the broad social structures that have entrenched so many Southerners in poverty and a more select group in their incapacity to obtain proper treatment. The argument of this paper is thus that the common approach in southern states, i.e., Abstinence Only curricula, has proven to be particularly ineffective and socially irresponsible in a region that is becoming increasingly rattled in disease. Though both of these factors are significant determinants of disease, neither one is the single source to address (2). Policies may be reformed, but the grander social forces need to be addressed by utilizing an alternative behavioral model in school teaching. Similarly, incidence of new disease may decrease with education reform, but if public policy inherently discriminates against groups of people, stigma will remain and undermine any efforts at prevention and treatment. Social change may either manifest itself through a bottom-up approach, i.e., through grassroots efforts, or through a top-down approach. This latter method has the ability to occur due to the specific effects that policy can potentially have on society. Over time, policies have the propensity to cause social norms to shift, thereby altering people’s behavior and the social structures around them. The exploration of public policy thus is an important part of Social Expectations Theory (4). As policies are passed, public opinion changes on a large scale, having an impact on social norms. In the case of HIV/AIDS, there are several policies currently in place that shroud the disease in stigma and denial. An essential component of reconstructing the current approach to HIV/AIDS prevention is thus to consider these policies, to be discussed below, so that access to treatment may improve and stigma may be absolved. When this is achieved and social norms are transformed, the widespread reluctance towards proper prevention education may potentially be diminished.
In order to emphasize the need to reform this approach to HIV/AIDS prevention, it is helpful to review the policies that are shaping the conditions within these states. There exist the policies that are faulty simply in their lack of funding or inappropriate standards (5). Then, there exist policies that are not rooted in scientific fact and therefore aid in the stigmatization of those living with HIV/AIDS (1). Both kinds of policies are necessary parts of the battle in improving the current approach to prevention, and both will be discussed below.
CRITIQUE ARGUMENT 1- CRIMINALIZATION OF HIV TRANSMISSION
As the prevalence of HIV/AIDS has increased, the means required to provide treatment have followed suit. The assistance procured in providing that treatment has been lacking, however (5). Instead, there are a number of policies in place, at both the state and national level, that serve to perpetuate a norm of HIV infection as worthy of shame. This process proves to be counterproductive in efforts towards prevention. Additionally, these approaches to containing the spread of HIV/AIDS undermine the ideas behind Social Expectations Theory. This theory asserts that you can change all of society by shifting the current social norms (4). The passage below will attempt to illustrate how current approaches to HIV/AIDS prevention could be more effective had they taken into consideration the far-reaching implications of Social Expectations Theory.
One current approach the prevent at prevention at the policy level is the criminalization of HIV. Under this policy, individuals who are aware of their HIV status and consequently transmit the disease to someone else can be sanctioned. However, no amendment is included in this policy to specify that transmission must be intentional (2). It is not even required for the transmission to have actually occurred. All that is required is a lack of disclosure to one’s sexual partner. Though this latter component is a crucial aspect to consider, the remainder of the policy poses serious threat to prevention efforts. If individuals fear criminalization, the likelihood of testing for HIV is greatly reduced, thereby undermining large scale screening efforts (2). Thinking on a broader scale, this trend of assigning “guilty” parties in this epidemic simply perpetuate stigma and downplay the importance of education. This form of criminalization has been prominent in southern states, such as Tennessee, Georgia, and Texas, proving to be a major threat to larger proportions of the southern population (2).
The social effects of HIV criminalization follow the principles of Social Expectations Theory. Laws punishing individuals for transmitting HIV, intentionally or unintentionally, foster a norm of fear and shame surrounding the disease. As a result, individuals who may have otherwise sought testing to determine their health status are significantly less likely to do so because the social structure in which they are embedded permeates a culture of punishment. The prevalent social norms deter individuals from adopting healthy behaviors (4). Thus, the criminalization of HIV transmission follows the Social Expectations Theory, but in a manner that is destructive, rather than conducive of HIV/AIDS prevention.
CRITIQUE ARGUMENT 2- OPPOSITION TO SYRINGE EXCHANGE PROGRAMS
A second faulty approach to HIV/AIDS prevention manifests itself in the current struggle with syringe exchange programs (SEPs). SEPs operate in a collaborative effort to to both prevent intravenous transmission by providing clean needles, as well as to connect drug users with services that make up a more comprehensive program. Individuals participating in these programs are often tested for HIV and other diseases, as well as connected to drug dependence treatment programs (2). Given that intravenous drug users make up a substantial portion of people living with HIV/AIDS in many southern states, i.e. 21% of infected individuals in Louisiana, SEPs serve as an ideal and innovative tool in prevention. Through this holistic process of providing clean needles and referral services, SEPs are notable in that they “meet people where they are” (2). They acknowledge the current needs of their beneficiaries and progress from there by providing the appropriate assistance. In the case of SEPs, individuals are not condemned for their behavior; instead, they are led onto a healthier track and provided with resources to gradually resume control. This approach has been praised for its effectiveness by such health-oriented organizations as Human Rights Watch and the Centers for Disease Control and Prevention (6).
One reason for this praise is the striking parallel that these programs run with the behavioral model, the Transtheoretical Model. This model asserts that individuals seeking to improve health behaviors progress gradually along a series of stages in a fairly structured order (7). SEPs, like many drug treatment programs, bear the same structure presented in the Transtheoretical Model. There are clear advantages to this model; namely, that it allows interventions to assess where an individual is in the process of adopting a particular health behavior and thus determine their readiness for next steps. Based on this determination, the specific intervention used may vary. A primary tenet of the model is that the process is gradual, rather than instantaneous, in that it entails a progressive change in the individual’s thought process (7).
In spite of the proven effectiveness of SEPs in particular regions of the country, there remain a set of laws and restrictions in the Southern United States that regulate the distribution of clean needles. Though larger concentrations of SEPs can be found in other regions of the country, they are few and far between in the southern states. This is largely due to the state laws that prohibit the sale or prescription of syringes for the injection of illegal substances (2). This policy undermines the Transthereotical Model’s approach in meeting people where they are. The current approach of outlawing the use of syringes for illegal substances suggests to individuals struggling with addiction that if they cannot immediately quit their behaviors, then they cannot be helped. This mindset has not had much proven success in other public health interventions, and this instance is no exception. The strict prohibition of providing clean syringes assumes that there is but a standard script to use in helping an individual overcome addiction. SEPs bear a striking parallel to the theory in that it assumes that individuals respond more or less successfully to different forms of intervention, depending on where they are in the process of dropping their addiction.
CRITIQUE ARGUMENT 3- EMPHASIS ON ABSTINENCE ONLY EDUCATION
A third manner in which southern states are fueling the HIV epidemic is through its widespread lack of access to sex and HIV/AIDS education in school. Although the South is certainly not the only area of the country experiencing some degree of reluctance to this standard, the escalating number of HIV cases indicate that there must be larger cultural structures in place making this reluctance more permeating. It is startling to consider the education policies that are currently in place in many of these states. While no state is required to emphasize the use of contraceptives, many states expect that it at least be addressed in school curricula. In a hand full of Southern states, however, no such expectation exists. Rather, several states require an emphasis on abstinence before marriage (2).
This lack of education does not take place within a vacuum, however. Both the Kaiser Foundation and the Centers for Disease Control and Prevention have published data indicating that among all cases of HIV/AIDS in the United States, a majority of recent infections has been among individuals in their teenage and young adult years (8). Southern states make up a largely disproportionate number of states with the highest number of teen pregnancies (2). These and other data indicate that an unavoidable portion youth in the South is indeed sexually active, despite many hopes or notions to the contrary. With the data indicating such a high percentage of youth engaging in sexual activity at a young age, any policy or law aimed at shielding them from any sort of cautionary information can be deemed socially irresponsible.
By using biased and misleading information, abstinence-only curricula heavily rely on the use of scare tactics to instill the belief that sex outside of marriage is immoral, thus making anyone who partakes immoral (9). Leaving students with a sense of ambiguity, this method perpetuates an association of sex with fear and shame. Actual harm comes into play as well, in that adolescents and young adults are barred from attaining vital, potentially life-saving information about sexual health (10).
Through this kind of curriculum, it not uncommon for students to be conditioned into associating abstinent individuals with honesty and prospects of success, as compared to viewing sexually active individuals as lacking good moral character (11). People who have premarital sex are thus perceived to be less desirable and are then impressed with a sense of shame. This concept runs parallel to the basic tenets of Labeling Theory (12). The implications of this theory are vast, in that individuals are influenced by the terms used to classify them. Additionally, the way they treat others is influenced by the labels ascribed to them. In the abstinence-only curriculum, adolescents may be introduced to negative labels of their sexually active peers that powerfully impact both groups’ behaviors, performance and even physiological factors. A variety of devastating emotional consequences including heartbreak, loneliness and feelings of regret place a heavy burden on the young adult population due to these programs (11). This approach inherently communicates a degree of loss in self-respect for individuals who participate in premarital sex, every time a sexual activity is initiated. These aforementioned emotional consequences are largely rooted in the teaching that adolescents who are or who will become sexually active, that they are worth less than their abstinent counterparts. For those few individuals who remain abstinent until marriage are left without any tools in which to communicate with their partners about sexual matters.
An additional, more apparent consequence of abstinence-only programs providing inaccurate information about sexually transmitted disease prevention or by completely eradicating information about prevention as a whole, is adolescents growing up with impeded abilities to make healthy sexual decisions (9). In order to prevent the spread of disease, adolescents must be educated on how to avoid them, learn how to recognize any possible symptoms and be encouraged to seek regular testing and medical attention without being fearful.
PROPOSED INTERVENTION 1- CHANGING SOCIAL NORMS
One proposal to fight these faulty approaches to HIV/AIDS approaches is to address the criminalization of HIV transmission. In order to attack the consequences of this policy, it is necessary to utilize its underpinning social theory; that is, Social Expectations Theory, or the theory that you can change all of society by changing the social norms pervading it (4). In the case of HIV criminalization, the social norm being perpetuated is that HIV transmission is an act of shame and moral deficit. As a result, sexually active individuals in states with criminalization laws become fearful of testing their HIV status (2). An alternative approach to address HIV prevention in these states would be change the norm by perhaps airing television advertisements about the importance of testing for HIV and other sexually transmitted diseases. These advertisements could come in the form of commercials showing couples getting tested together. The commercials could use certain dialogue to paint the situation in a way that purveys it as an experience of emotional closeness and growth between a couple. A second possible method would be secure agreements with television networks or program writers to incorporate HIV testing into the story lines of their programs. Television programs viewed by teenagers and young adults largely consist of story lines centered around of plot of romance, leaving much room to seamlessly integrate a situation where one or more characters gets tested. It would, of course, be ideal for the decision to get tested to be portrayed as a natural and obvious course of action for the character. Additionally, the situation should be portrayed in a positive light, perhaps by having the character testing negative and feeling relieved.
These and other interventions would likely prove to be very effective in this case by portraying awareness of one’s HIV status as a responsible and necessary course of action. Ideally, this would have a gradual effect on social norms, leaving an increasing number of people taking responsibility for their health and knowing their HIV status” (4). The current approach used by some states of criminalizing the transmission of HIV is an effective method aimed at prevention. This is a method that is short-sighted and attempts a simplistic solution at prevention. Instead of punishing individuals for their behaviors, people should be encouraged to assume control and an active role in their health.
PROPOSED INTERVENTION 2- MEETING PEOPLE WHERE THEY ARE
A second necessary approach is to drift away from the current restriction of providing clean syringes in certain states. Currently, drug users that use syringes to inject substances into their body are risking using contaminated needles because they have no means of attaining clean ones, facilitating the spread of disease. Lawmakers that set restrictions on needle distributions are doing so with the underlying belief that drug users are as such because of a lack of discipline and irresponsibility and need to abruptly quit their behaviors. This is, again, a simplistic view of a legitimate medical and psychological problem. Successful efforts need to be geared to assist individuals at various stages in the process of quitting, thereby utilizing the Transtheoretical Model (7). This can be done by lobbying for policy reform that will lift restrictions on physicians’ abilities to provide safe needles. Justification for such legislation includes that it is socially responsible and has the long term potential to improve the public’s health, as well as to cut costs in HIV/AIDS-related health care. If physicians, from hospital emergency rooms or community health centers, could provide clean needles and simultaneously connect individuals to treatment programs for drug addiction, southern states would be on the path to a sustainable project in gradual reduction of HIV incidence. This use of the Transtheoretical Model is sensitive to the varied needs of a large population and encompasses a wide range of interventions people, depending how much progress they have made in ceasing, or considering to cease, illegal drug use (7).
PROPOSED INTERVENTION 3- COMPREHENSIVE SAFE SEX EDUCATION
Finally, a third way to address the increasing incidence of HIV in the Southern United States would be to address the lack of sex education and STD prevention curricula in schools. Many schools, in an attempt to discourage sexual activity, inadvertently instill in students a stigma attached to sex. This stigma, by extension, aids to form a negative label on sexual active students (12). A possible approach to reverse this trend would be to require that school place a strong emphasis on safe sex, and not simply address it while placed an emphasis on abstinence before marriage. Shifting the norm from viewing sex as mysterious and shameful to a topic around which teenagers can engage in meaningful dialogue would hopefully have the effect of lifting the label off of sexually active individuals (4). As a result, individuals would have more accessible information on safe sexual activity.
The threat of HIV/AIDS is not a peripheral issue to this country’s youth. However, various policies persist in the South and other regions of the country that pose a serious threat to the AIDS response. Criminalization of HIV transmission, restrictions on syringe exchange programs, and lack of access to safe sex information are but a few examples of such challenges. These attempts at prevention the spread of the HIV/AIDS have only worked to fuel the epidemic, as evidenced by the disproportionate number of cases in the South. Various social theories can be used to examine as to why these interventions have been unsuccessful. If policymakers are to make an impact in their goal of prevention, they will need to reconsider the theories underlying their interventions. Ensuring that injection drug users and various segments of our nation’s youth are empowered to access comprehensive and appropriate packages of HIV prevention, treatment, and support services is essential to the fight against HIV/AIDS.
1. Human Rights Watch. Southern Policies Fuel HIV Epidemic: Outdated Approaches, Ineffective Strategies, Punitive Laws at Nation’s HIV Epicenter. 26 November 2010. New York. http://www.hrw.org/en/news/2010/11/26/us-southern-policies-fuel-hiv-epidemic
2.Human Rights Watch. Southern Exposure: Human Rights and HIV in the Southern United States. Human Rights Watch. November 2010.
3.Aschengrau, A.; Seage, G. Essentials of Epidemiology in Public Health. Jones & Barlett Learning. June 2007.
4.Siegel, M. “Group Level Models”. Boston University School of Public Health, Lecture Notes. 28 October 2010.
5. United States General Accounting Office. Ryan White Care Act of 1990: Opportunities to Enhance Funding Equity. November 1995.
6.Human Rights Watch. Injecting Reason: Human Rights and HIV Prevention for Drug Users. New York. September 2003. http://www.hrw.org/en/node/12269/section/1
7.Siegel, M. “Traditional Individual Level Models.” Boston University School of Public Health, Lecture Notes. 7 October 2010.
8.Kaiser Family Foundation. HIV/AIDS Policy Fact Sheet. September 2009.
9.Kay, J.; Jackson, A. “How Abstinence-Only Programs Harm Women and Girls”. Sexuality and Family Rights Legal Momentum, Advancing Women’s Rights. 2008.
10. Kornman, A. “A Critique of the Abstinence-Only Approach: A Consideration of Adolescent Decisional Development and Democratic Sexual Citizenship”. University of Pittsburgh. 2008.
11. Harding, D. “Take Action for Comprehensive Sex Ed Tomorrow!” 8 February 2010. http://www.progressohio.org/page/community/post/daveharding/CXzH
12. Siegel, M. “Labeling & Stigma Theory”. Boston University School of Public Health. 2 December 2010.