The Social Epidemiology of Human Immunodeficiency
Virus/Acquired Immunodeficiency Syndrome
K. E. Poundstone, S. A. Strathdee and D. D. Celentano
From the Department of Epidemiology, Johns Hopkins Bloomberg School
of Public Health, Baltimore, MD.
Correspondence to Dr. David D. Celentano, Infectious Diseases
Program, Department of Epidemiology, Johns Hopkins Bloomberg School of
Public Health, 615 North Wolfe Street (E6008), Baltimore, MD 21205
(e-mail: firstname.lastname@example.org ).
Received for publication June 18, 2003; accepted for publication
February 6, 2004.
Abbreviations: AIDS, acquired immunodeficiency syndrome; HIV, human
immunodeficiency virus; STD, sexually transmitted disease.
Social epidemiology is defined as the study of the distribution of
health outcomes and their social determinants (1). It builds on the
classic epidemiologic triangle of host, agent, and environment to focus
explicitly on the role of social determinants in infectious disease
transmission and progression. These determinants are the "features of
and pathways by which societal conditions affect health" (2, p. 697).
Early studies of human immunodeficiency virus (HIV)/acquired
immunodeficiency syndrome (AIDS) focused on individual characteristics
and behaviors in determining HIV risk, an approach that Fee and Krieger
(3) refer to as "biomedical individualism." Biomedical individualism is
the basis of risk factor epidemiology; by contrast, the social
epidemiology perspective emphasizes social conditions as fundamental
causes of disease (4) (table 1). Social epidemiologists examine how
persons become exposed to risk or protective factors and under what
social conditions individual risk factors are related to disease. Social
factors are thus the focus of analysis and are not simply adjusted for
as potentially confounding factors or used as proxies for unavailable
individual-level data. Social factors are indeed critical to
understanding nonuniform infectious disease patterns that emerge as a
result of the dependent nature of disease transmission or the idea that
an outcome in one person is dependent upon outcomes and exposures in
others (5, 6).
TABLE 1. Comparison of how HIV*/AIDS* epidemiology is examined by
using different research paradigms
|Key research questions
|Understanding of risk
|Implications for interventions
|Risk factor epidemiology
||What places persons at risk of
acquiring HIV infection? What individual characteristics are
associated with development of AIDS and disease progression?
||Risk of HIV/AIDS is manifest at
the individual level.
||Interventions focus on
individual behavior change to prevent HIV transmission.
Interventions focus on access to clinical AIDS care.
||What places populations at risk
of HIV epidemics? What population characteristics enhance
vulnerability to HIV/AIDS epidemics?
||Social determinants affect
HIV/AIDS risk by shaping patterns of population susceptibility
||Policy and program interventions
that address fundamental social determinants will enable large
reductions in HIV/AIDS at the population level.
|A psychosocial approach
||How do social factors influence
psychology or behavior to place persons at higher risk of HIV
infection? Are psychosocial factors such as social support
associated with AIDS disease progression? How are behavioral and
social factors interrelated?
||Psychosocial factors mediate the
effects of social structural factors on individual risk.
Psychosocial factors are conditioned and modified by the larger
social context in which they occur.
||Interventions focus on modifying
interpersonal relationships to enable HIV prevention or to
improve health outcomes for persons living with HIV/AIDS.
|A social production of disease
or political economy of health approach
||How do economic and political
determinants help establish and perpetuate inequalities in
HIV/AIDS distribution within and between populations?
||Limited access to resources
places persons at risk of HIV infection and AIDS disease
||Changes to the structure of the
social environment through legal, political, or economic
intervention are necessary to empower vulnerable groups to
protect themselves against HIV/AIDS.
|An ecosocial approach
|How do factors at multiple
levels—from the microscopic to the societal—contribute to the
creation of population-level patterns of HIV/AIDS?
|HIV/AIDS risk is "embodied"
among persons over lifetime exposures to numerous biologic and
|Responsibility for factors that
enhance vulnerability may be located at multiple levels; as
such, interventions should be targeted to the level specified
through ecosocial studies.
* HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency
In this table, a distinction is made between three approaches to
studying social epidemiology: a psychosocial approach, a social
production/political economy of disease approach, and an ecosocial
approach. This table is based on work by Krieger (181).
Contact patterns that enhance HIV/AIDS vulnerability may be
conceptualized at multiple levels. Figure 1 distinguishes determinants
of HIV/AIDS at three levels: individual, social, and structural.
Individual factors include biologic, demographic, and behavioral risk
factors that may influence the risk of HIV acquisition and disease
progression. Social-level factors include critical pathways by which
community and network structures link persons to society. These
structures are central to understanding the diffusion and differential
distribution of HIV/AIDS in population subgroups. Structural-level
factors include social and economic factors, as well as laws and
policies. These factors, in turn, affect HIV transmission dynamics and
the differential distribution of HIV/AIDS.
FIGURE 1. A heuristic framework for the social epidemiology of human
immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS).
The dotted lines separating the levels illustrate the porous nature of
the distinctions made between levels of analysis. In reality, there are
extensive linkages between factors at all levels that give rise to
observed epidemic patterns. STI, sexually transmitted infection.
Infectious disease epidemiology provides models of the mechanisms
through which social determinants affect HIV transmission (7). For
example, the basic reproductive number of an infectious disease, R0 (8),
describes secondary infections that arise from a primary infection. In
the equation R0 = ßCD, ß is the probability of infection per contact, C
is the number of contacts, and D is the duration of infectivity. The
goal of intervention efforts is to reduce the empirical value of these
terms by modifying the social conditions under which individual risk
factors lead to disease. Examples of factors that affect the component
terms of R0 in HIV epidemiology are presented in table 2.
TABLE 2. Component terms in the equation for the basic reproductive
number, and factors that affect the empirical estimates of the terms in
the case of HIV*
|Factors affecting the term
|Social or structural approaches
to reducing the term’s value (reference number(s))
||100% condom policies (182–184)
||Low infectivity of HIV
||Ensuring access to care
treatment for sexually transmitted infections (108, 178, 185,
||Sexual practices, such as dry
||Number of sex or injection drug
||Needle exchange programs to
minimize direct contact between persons sharing drugs (187, 188)
||Rate of sex partner acquisition
||Network interventions to reduce
the number of risky contacts between persons by promoting harm
reduction practices and condom use (36, 189–191)
||Timing of sexual partnerships
||Structural interventions to
reduce risk (114, 174)
||Mixing patterns (assortative/disassortative)
||Increased availability of
voluntary counseling and testing programs (192, 193)
||Size of core groups
||Population turnover in core
||Duration of infectiousness
||Natural history of infection
||Ensuring access to care for
HIV/AIDS* to reduce infectiousness by decreasing viral load
* HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency
In this review, we present existing evidence linking social and
structural determinants to HIV/AIDS. In addition, we discuss the
implications of these findings for future social epidemiology research
on HIV/AIDS as well as the design of more effective HIV/AIDS
MATERIALS AND METHODS
We searched the published literature to identify conceptual and
empirical research reports on the social epidemiology of HIV/AIDS. Five
databases were searched: PsycINFO (American Psychological Association,
Washington, DC), PubMed (MEDLINE; National Institutes of Health,
Bethesda, Maryland), Social Science Citation Index (Web of Science;
Thomson ISI, Stamford, Connecticut), Sociological Abstracts (CSA,
Bethesda, Maryland), and Digital Dissertations (ProQuest; UMI, Ann
Arbor, Michigan). Searches were designed to include the factors we
specified in our framework as social or structural factors (figure 1).
Searches were limited to published articles in the English language for
the period 1981–2003. The following keywords were included in each
search: AIDS/acquired immunodeficiency syndrome, HIV, and epidemiol*.
Additional searches were conducted by using combinations of keywords
listed in Appendix table 1 corresponding with our framework.
RESULTS: SOCIAL-LEVEL FACTORS AND HIV/AIDS
We identified four categories of social-level factors of importance
to HIV/AIDS epidemiology: cultural context, social networks,
neighborhood effects, and social capital. Each uses different conceptual
and methodological approaches to examine the effects of social forces on
population HIV/AIDS vulnerability.
Anthropologist Edward Tylor defined culture as "that complex whole
which includes knowledge, belief, art, law, morals, custom, and any
other capabilities and habits acquired by man as a member of society"
(9, p. 1). Anthropologic and epidemiologic approaches may be integrated
in a variety of ways to identify features of the social environment that
affect HIV/AIDS risk. One way to explore how the social environment
affects HIV/AIDS epidemiology is through the use of mixed research
methods. Mixed-methods study designs integrate qualitative and
quantitative research methods either sequentially or concurrently (10).
In sequential study designs, qualitative methods may be used to explore
a topic under study or to explain quantitative epidemiologic findings.
Concurrent study designs are meant to confirm, cross-validate, or
corroborate findings within a single study. A common type of concurrent
mixed methods study is "triangulation," and this approach has been used
extensively in rapid assessments of illicit drug use and HIV/AIDS
(11–13). Mixed methods approaches are particularly well suited to the
investigation of the often hidden and stigmatizing behavioral and social
factors underlying HIV epidemics.
One exemplary study combining qualitative methods with quantitative
methods was conducted by Beyrer et al. (14) to examine the role of
overland heroin trafficking routes in shaping explosive HIV/AIDS
epidemics among injection drug users in Southeast Asia. Piecing together
data from a variety of sources, including existing epidemiologic data,
key informant interviews, and laboratory data, this study revealed that
distinct HIV subtypes emerged and recombined along drug trafficking
routes originating in Myanmar, one of the world’s largest heroin
producers. Along these trafficking routes, communities of injection drug
users formed, facilitating the spread of HIV into local communities in
Laos, Thailand, Vietnam, India, and China (refer, for example, to Panda
et al. (15)). This illustration highlights the broader understanding of
HIV/AIDS epidemiology that can be achieved by examining the interplay
between contextual factors and social and behavioral factors.
Investigation of social networks in HIV/AIDS began with the mapping
of relationships between one of the first identified AIDS cases, an
airline steward, and a large number of his male sex partners in the
early 1980s (16). Social network analysis generates measures of the
quality, density, position, and structure of relationships between
persons, including dyads (partnerships), personal networks ("egocentric"
networks), and larger communities ("sociometric" networks) (17, 18).
Social networks can influence health outcomes in direct and indirect
ways, including 1) social influence, 2) social engagement and
participation, 3) prevalence of infectious disease and network member
mixing, 4) access to material goods and informational resources, and 5)
social support (19). Researchers have demonstrated that patterns in the
structure of relationships—rather than differences in individual risk
behaviors alone—explain observed HIV patterns (20, 21).
The theoretical foundation for examining social networks in HIV
research is closely tied to advances in sexually transmitted disease
(STD) epidemiology. A key concept from STD epidemiology is the notion of
the "core group," a small group of disease transmitters responsible for
a large proportion of cases (22). Friedman et al. (23) found that
individuals’ locations within sociometric risk networks were associated
with HIV risk among a group of injection drug users in New York City.
Other concepts from STD epidemiology, such as partner concurrency,
bridging, and mixing patterns, are also important in understanding HIV
risk (24–29). Specific network characteristics that have been associated
with HIV/AIDS include the size of subgroups and their distribution in a
network (23), the centrality of HIV-positive persons within networks
(30), partner selection patterns (24, 31–33), and concurrent sexual
partnerships (28). Inclusion of these variables has been shown to
improve transmission estimates in mathematical modeling (34, 35).
Social and normative influences have also been associated with
individual HIV risks (36, 37). Network-related social and normative
influences are predictive of illicit drug use (38) and condom use
behavior (37, 39), highlighting the importance of network-based
interventions for HIV prevention (18). Kelly et al. (40, 41) developed a
popular opinion leader model that has been effective in reducing HIV
risk in several populations, including men who have sex with men and
women in low-income housing (42). The success of this model has led to
its adaption for international use by the National Institute of Mental
Health Collaborative HIV/STD Prevention Trial in China, India, Peru,
Russia, and Zimbabwe.
Neighborhoods represent the intersection of social networks and
physical spatial locations, a confluence Wallace (43) has called the "sociogeographic
networks" through which infectious diseases spread. Early interest in
the role of neighborhood social environment in disease transmission was
sparked by a study in Colorado Springs, Colorado, in which researchers
found that gonorrhea was highly focused geographically in core
residential neighborhoods (44). Both direct and indirect mechanisms may
determine how neighborhood-level factors shape population HIV/AIDS
patterns. Direct mechanisms are those that increase the likelihood of a
person coming into contact with someone who is HIV positive, for
example, through residential segregation and the social isolation of
marginalized populations. Indirect mechanisms include those that
increase population vulnerability to HIV/AIDS, such as exposure to poor
socioeconomic conditions, high unemployment, or the proliferation of
illicit drug markets. A range of neighborhood-level factors have been
examined in relation to infectious disease, including poverty and income
(45, 46), residential segregation (47), and neighborhood physical
environment (48, 49). Current research in neighborhood and area effects
on health emphasizes the importance of moving beyond documentation of
associations to analyze the social and epidemiologic mechanisms through
which neighborhood effects might operate (50–54).
Increasing concentrations of affluence and poverty are contributing
to what demographer Douglas Massey has called "a radical change in the
geographic basis of human society" (55, p. 395). Powerful social and
economic forces in US cities are increasing neighborhood segregation by
class and race/ethnicity (56, 57). Resulting social disorganization and
loss of resources and services in poor neighborhoods are in turn shaping
HIV/AIDS patterns at the neighborhood level. In a number of studies in
New York City, for example, Wallace (58–63) has examined the complex
interplay of public policies such as "planned shrinkage" with HIV
epidemic dynamics in the Bronx, documenting the "synergy of plagues"
that has accompanied rapid social change and the destruction of
essential protective networks in poor communities. Using AIDS
surveillance data, ecologic studies conducted in various US cities have
also consistently found significant associations between income and
poverty measures and neighborhood-level AIDS incidence and prevalence
rates, and these findings have been consistent across census block
groups (46), census tracts (64), and zip codes (65, 66). Length of
survival after an AIDS diagnosis has also been linked with neighborhood
measures of income both before and after the introduction of highly
active antiretroviral therapy (HAART) (64, 67–69). Income inequality, a
powerful predictor of health at the population level (70), may also play
a role in shaping HIV/AIDS patterns, although associations between
HIV/AIDS and income inequality at the neighborhood level have not been
Residential segregation by race/ethnicity is another
neighborhood-level process that may play an important role in HIV/AIDS
disparities (47). Segregation may affect infectious disease patterns
through the concentration and isolation of persons in one racial/ethnic
group, increasing the probability of transmission within that group. For
example, Acevedo-Garcia (71) found that measures of residential
isolation were protective against tuberculosis for Whites but placed
African Americans at greater risk of disease. Indirect effects of
racial/ethnic segregation are associated with low levels of neighborhood
political capital and with attenuated life chances for those living in
poor neighborhoods (72). While segregation may contribute to
understanding racial/ethnic disease disparities, we know of no studies
examining neighborhood racial/ethnic segregation in relation to HIV/AIDS
that have been reported.
The physical environment of neighborhoods has also been examined in
relation to infectious disease. Cohen et al. (48) examined gonorrhea
rates and neighborhood physical environment in New Orleans, Louisiana,
by using an index of physical deterioration to explore Wilson and
Kelling’s (73) "broken windows" theory. According to this theory, the
presence of physical incivilities such as graffiti and litter prompt a
breakdown in social order, resulting in a cascade of negative community
outcomes. Extending this concept to public health, Cohen et al. (49)
found a significant association between neighborhood physical
deterioration and gonorrhea rates, a finding confirmed by a subsequent
ecologic study of 107 US cities. Neighborhood physical environment may
heighten HIV risk by influencing illicit drug use practices, such as
injection behaviors and needle sharing (74, 75). Further exploration of
the mechanisms through which the observed associations may be operating
and associations between the physical environment and HIV/AIDS is
Continued research is needed to support the design of
neighborhood-level HIV/AIDS interventions. As Diez Roux has argued, "[n]eighborhood
differences are not ‘naturally’ determined but rather result from social
and economic processes influenced by specific policies. As such, they
are eminently modifiable and susceptible to intervention" (52, p. 518).
The current body of evidence demonstrates strong ecologic associations
between neighborhood-level factors and infectious disease that need to
be explored further to identify points of policy and programmatic
Sociologist James S. Coleman defined social capital as aspects of
social structures that facilitate collective action, emphasizing that
"social capital is productive, making possible the achievement of
certain ends that in its absence would not be possible" (76, p. S98).
Social capital may affect health through 1) the presence of
health-promoting behaviors; 2) access to services and amenities; 3)
levels of mutual trust in a community; and 4) greater political
participation, leading to policies that are more likely to benefit all
Two published studies have explicitly examined social capital in the
context of HIV/AIDS. In the United States, Holtgrave and Crosby (78)
examined poverty, income inequality, and social capital as predictors of
state-level STD and AIDS rates; they found social capital to be the
strongest predictor of both STD and AIDS rates. In South Africa,
Campbell et al. (79) examined one aspect of social capital, civic
participation, as a proxy for understanding community influences on HIV
infection. They found that participation in certain types of
organizations (e.g., churches, sports clubs, and youth groups) was
protective, while membership in other social groups (e.g., groups with
high levels of social drinking) increased HIV risk. While suggestive,
findings from these studies are preliminary and warrant further
RESULTS: STRUCTURAL-LEVEL FACTORS
We identified five main categories of structural-level factors
relevant to HIV/AIDS epidemiology: structural violence and
discrimination, legal structures, demographic change, the policy
environment, and war and militarization. Each is discussed in the
paragraphs that follow.
Structural violence and discrimination
Structural violence highlights a kind of institutionalized harm
"...‘structured’ by historically given (and often economically driven)
processes and forces that conspire—whether through routine, ritual, or,
as is more commonly the case, the hard surfaces of life—to constrain
agency" (80, p. 40). Structural violence is most frequently manifested
in patterns of discrimination based on race/ethnicity, gender, sexual
orientation, and HIV status. A conceptualization of how structural
violence might influence HIV/AIDS risk is presented in figure 2.
FIGURE 2. Pathways through which various forms of structural violence
might influence the risk of human immunodeficiency virus (HIV)/acquired
immunodeficiency syndrome (AIDS).
Race/ethnicity and racism. The meaning and uses of race/ethnicity in
epidemiologic research have been the subject of extensive analysis and
debate (81–85). Social epidemiologists view race/ethnicity as an
indicator of social forces rather than physical difference. LaVeist (81)
has argued that race/ethnicity is a proxy for exposure to racism, which
may be defined as the "institutional and individual practices that
create and reinforce oppressive systems of race relations" (86, p. 195).
The study of racial/ethnic disease differentials is of central
importance in the study of HIV/AIDS disparities. In the United States,
for example, African Americans experience the highest levels of HIV
prevalence, HIV/AIDS incidence, HIV/AIDS-associated mortality, and years
of potential life lost (87); Hispanics also experience
disproportionately high HIV/AIDS burdens compared with Whites (88–90).
Studies of behavioral risk factors at the individual level have not
fully explained observed HIV/AIDS or STD differentials by race/ethnicity
(91–94). Beyond individual behaviors, pathways by which HIV/AIDS becomes
concentrated in a particular racial/ethnic group involve complex
processes of economic and social deprivation, socialization patterns,
socially inflicted trauma, targeted marketing of illicit drugs, and
inadequate health care (95). Social epidemiology is providing new
insights and evidence as to what factors and processes underlie these
racial/ethnic HIV/AIDS differentials. Laumann and Youm (31) found that
sexual networks accounted for racial/ethnic variations in self-reported
sexually transmitted infection rates in the National Health and Social
Life Survey. Similarly, Kottiri et al. (96) found that risk network
structure in a cohort of injection drug users explained variations in
racial/ethnic differences in HIV prevalence between African Americans
and Whites. Contextual and structural factors play key roles in shaping
the socialization patterns that contribute to racial/ethnic HIV/AIDS
disparities. For example, the socially destabilizing effects of low
male-to-female sex ratios resulting from the disproportionate
incarceration of African-American men may be discouraging monogamous
relationships and promoting sexual partnership concurrency (97).
Residential segregation by race/ethnicity also appears to shape social
and risk networks in ways that contribute to endemic disease patterns.
Racial/ethnic residential segregation was strongly and independently
associated with endemic gonorrhea rates at the county level in the
southeastern United States (98). Similar patterns might be observed for
Gender and sexism. There is considerable heterogeneity in the
proportion of women among HIV/AIDS cases around the world. Women
accounted for 20 percent of HIV-positive adults in North America through
2002 and for 58 percent of HIV-positive adults in sub-Saharan Africa
(99). HIV infections in women are rising at an alarming rate, and women
are both biologically and socially more vulnerable to HIV infection.
Several theoretical frameworks for understanding gender differentials in
HIV/AIDS have been put forth, including feminist, political economy, and
human rights frameworks (100). Looking beyond gender as a simple risk
category, these approaches seek structural explanations for gender
differentials in HIV/AIDS.
Although substantial focus has been placed on women in the roles of
sex workers or mother-to-child transmission (101), most women acquire
HIV from their sole regular partner (102, 103), and reducing acquisition
of HIV among men is key to reducing the spread of HIV to women (104,
105). Women face violence, the threat of rejection, and significantly
greater stigma and discrimination than their male partners upon
disclosure of HIV-positive test results, in part because of power
differentials of gender and HIV risks experienced by women (106).
Stigma, discrimination, and collective denial. The effects of stigma
include individual reluctance to seek HIV testing and a lack of
empowerment to enact HIV prevention (107). The Centers for Disease
Control and Prevention estimates that approximately one third of those
with HIV do not know their HIV status (108). Stigma, discrimination, and
collective denial have played central roles in shaping responses to
HIV/AIDS epidemics, yet the effects of these social forces on the
differential distribution of HIV/AIDS have not been well examined.
Stigma has usually been examined at the individual level in studies of
perceptions and interpersonal interactions (109). Link and Phelan
reconceptualized stigma to apply "when elements of labeling,
stereotyping, separation, status loss, and discrimination co-occur in a
power situation that allows the components of stigma to unfold" (109, p.
367). Herek et al. have defined stigma as "the prejudice, discounting,
discrediting, and discrimination that are directed at people perceived
to have AIDS or HIV and at the individuals, groups, and communities with
which these individuals are associated" (110, p. 36). Parker and
Aggleton have argued that a new conceptual framework for understanding
HIV/AIDS-related stigma is needed "to reframe our understandings of
stigmatization and discrimination to conceptualize them as social
processes that can only be understood in relation to broader notions of
power and domination" (111, p. 16 (italics in original)).
Herek et al. (112) reported that mistaken beliefs about HIV
transmission and negative feelings toward people with AIDS remain
prevalent. To overcome the negative consequences of stigma,
environmental or structural interventions must change the context in
which individuals and communities view HIV infection (111, 113–115). The
most effective responses have been those in which affected communities
have mobilized to fight stigma and discrimination by increasing
community awareness of HIV (116–118). Social interventions to overcome
stigma and discrimination aim to affect collective community change. The
rationale for this action is found in diffusion theory, which focuses on
social networks, opinion leaders, and change agents (119). Although
these elements are influenced by global cultural trends portrayed
through the media, immediate interpersonal interactions occurring in
social networks within specific communities are essential for inducing
and maintaining behavior change to facilitate productive responses to
Legal structures refer to laws, as well as to the institutions and
practices involved with their creation, implementation, and
interpretation (121). Burris et al. (122) argue that laws can affect
health in two ways: 1) they may be a pathway through which social
determinants affect health (a direct effect), and 2) they may contribute
to social conditions associated with health outcomes (an indirect
effect). An example of direct effects of law on HIV risk are legal
restrictions on access to sterile injection equipment, which have been
associated with higher HIV incidence (123). An example of an indirect
effect of legal structures is the effect of tax laws on income
inequality, which may foster social conditions that increase HIV
vulnerability. Laws underlie many key social determinants of HIV/AIDS,
including housing, poverty and income inequality, racism, and community
social organization (124).
Demographic change may affect HIV/AIDS patterns through population
mobility and migration, urbanization, and the age and gender structures
of subpopulations. Each of these factors may be seen as modifying
interactions between susceptible and infected persons in populations.
Mobile populations around the world experience higher HIV infection
rates than nonmobile populations, regardless of HIV prevalence in the
origin or destination location (125–127). Labor migration, refugee
migration, resettlement, internal migration, and commuting may affect
HIV transmission rates. Epidemiologic studies of migration have fallen
into two main categories: 1) studies of the spread of HIV along
transportation corridors, and 2) studies of the migration process that
increases vulnerability to HIV/AIDS (125). Molecular techniques can
trace the spread of HIV viral subtypes and circulating recombinant forms
to document patterns of mobility and migration. Perrin (128) recently
reviewed evidence linking travel patterns and HIV. Beyrer et al. (14)
found that distinct HIV subtypes were associated with different illicit
drug trafficking routes in Southeast Asia. Long-distance truck driving
has contributed to the spread of HIV in Africa, India, and South America
(129–133). In addition, studies have identified the importance of
migrant labor in the creation of markets for prostitution (134).
HIV/AIDS is a classic example of an urban health problem, yet few
have directly examined the role of urbanization processes in generating
population HIV/AIDS patterns (135). Factors that might account for the
effects of urbanization on HIV/AIDS patterns include altered sexual and
drug use patterns due to changes in socialization patterns, in- and
outmigration of infected and susceptible persons, and increased burdens
on the health care system.
Male-to-female sex ratios that favor men have also been associated
with high HIV/AIDS prevalence rates at the country level (136). This
ecologic association is likely to be modified by the effects of cultural
context at the local level because of the varied effects skewed gender
ratios might have on partnership formation and network patterns.
The policy environment
Policies guide decisions about the allocation of scarce resources in
both the public and private sectors, and the policy environment plays a
central role in the emergence and control of HIV/AIDS epidemics. Policy
realms of particular importance to HIV/AIDS include macroeconomic
policy, health policy, social policy, and illicit drug control policy.
HIV/AIDS is exacting a high toll on the macroeconomic health of many
developing nations, and macroeconomic policies are likely to be
contributing to increasing HIV/AIDS burdens. The complex and reciprocal
relations between macroeconomic policies and HIV/AIDS are only beginning
to be explored. Macroeconomic policies affect health and development by
altering absolute poverty levels and/or inequalities in the distribution
of wealth (137), thereby affecting household economies and health
systems investment (138). Some have argued that World Bank structural
adjustment programs designed to stimulate private-sector growth and
exports in debtor countries have had a negative impact on the HIV/AIDS
pandemic by undermining rural subsistence economies, expanding
transportation infrastructure, increasing migration and urbanization,
and reducing investment in the health and social services sectors (139).
Questions remain as to how macroeconomic policies can be designed to
contribute to reductions in HIV/AIDS internationally.
Structural-level health policies governing prevention, treatment, and
care can contribute to dramatic reductions in HIV/AIDS incidence. HIV
prevention strategies have typically centered on individual behavior
change, but the scope of the HIV prevention policy is widening with
recognition of the need for multisectoral programs that address the
social and economic aspects of HIV/AIDS (140, 141). The Thai 100 percent
condom program is an exemplary example of an effective multisectoral
structural HIV prevention program intended to alter the environment in
which HIV risk behaviors occur (142). Policies governing the provision
of antiretroviral therapy may also affect reductions in HIV/AIDS
transmission by reducing viral load among HIV-positive persons.
Social policies assume a critical role in the lives of those most
vulnerable to HIV/AIDS, such as low-income, marginally housed, or
addicted persons. Social policies governing programs such as welfare and
public assistance directly affect access to resources and can also
affect HIV transmission and access to care. Little quantitative research
has linked social policy change to population health outcomes (143), but
qualitative research has highlighted the importance of social policy in
shaping HIV/AIDS-related risk behavior. In San Francisco, California,
for example, Crane et al. (144) documented the harmful effects of the
Personal Responsibility and Work Opportunity Reconciliation Act of 1996,
which eliminated Social Security Income and Social Security Disability
Insurance eligibility on the basis of drug addiction and alcoholism.
Participants in this study reported being driven back into the
underground drug economy because of income loss, dropping out of
methadone treatment because they lost benefits, and engaging in
high-risk behaviors in an attempt to acquire HIV to regain lost
benefits. Further studies of the associations between social policies
and HIV/AIDS are desperately needed to document the human costs of
policies out of sync with the needs of those most vulnerable to HIV/AIDS
and to identify potential solutions.
Illicit drug control policy also has a significant impact on
HIV/AIDS. Injection drug use, particularly of opiates, is driving HIV
epidemics in many countries around the world. The global "War on Drugs"
has focused primarily on supply control to the neglect of demand
reduction, which consists of substance abuse prevention and treatment
measures (145). Widespread "zero tolerance" policies promoting strict
enforcement for those trafficking or possessing illicit drugs have
resulted in escalating numbers of persons incarcerated for drug
offenses. The direct HIV/AIDS-related consequences of enforcement
patterns appear to be negative (146–149). For example, Blumenthal et al.
(150) found that War on Drugs policies such as the criminalization of
syringe possession and disqualification of those with substance use
problems from supplemental Social Security Income programs were
associated with increases in high-risk behaviors. Incarceration itself
is a known risk factor for HIV. HIV risk behaviors have been shown to
persist during incarceration (151–157), generally associated with higher
rates of needle sharing (158) and HIV risk (159). Despite ample supplies
of drugs in many prison settings, inmates rarely have access to sterile
War and militarization
War can increase HIV/AIDS risk indirectly and directly by disrupting
normal social and risk networks, weakening or destroying medical
infrastructure, and increasing poverty and social instability in
conflict areas (160). Changes in risk behaviors in times of military
conflict have been documented. For example, Strathdee et al. (149) found
that the war in Afghanistan was associated with increased needle sharing
among injection drug users in neighboring Pakistan, possibly because of
the disruption of regular heroin trafficking from Afghanistan.
In the absence of open conflict, the degree of militarization has
also been associated with country-level HIV/AIDS rates. Military forces
are often located near urban centers and consist of young men away from
home. In a study for the World Bank, Over (136) found that a reduction
in the size of the military from 30 percent to 12 percent as a
proportion of total urban population could reduce HIV seroprevalence
among low-risk urban adults by 1 percent. Policies to limit the presence
of troops in urban areas are likely to reduce HIV risks, especially in
conjunction with HIV/AIDS prevention and screening programs for military
The contributions of social epidemiology to the battle against
HIV/AIDS have grown in recent years. This finding is due in part to a
general trend that Koopman calls epidemiology’s "transition from a
science that identifies risk factors for disease to one that analyzes
the systems that generate patterns of disease in populations" (161, p.
630). Conceptual and methodological developments in the field have
facilitated this transition, expanding our understanding of multiple
causes of risk (162–167). Advances in multilevel modeling (162),
geographic information systems software (168–170), and databases linking
public health data with information on social factors (171, 172) all
enhance our ability to develop and test hypotheses about causation in
ways that more closely match the contours of HIV/AIDS epidemics.
Ultimately, social epidemiology research in HIV/AIDS will help determine
how we can design more effective sets of interventions at multiple
levels of social organization (173–175).
A number of key challenges remain. First, clear, testable hypotheses
about which aspects of the larger social environment matter in HIV/AIDS
transmission and disease progression are needed, requiring theory-based
model specification. Second, complex measurement and analytical issues
must be addressed. As Diez Roux has pointed out, these issues include
"nested data structures, variables and units of analysis at multiple
levels, contextual effects, distal causes, and complex causal chains
with feedback loops and reciprocal effects" (52, p. 516). Finally,
multisectoral approaches are required for the effective implementation
of social-level interventions.
Globally, 40 million persons are now living with HIV/AIDS, and an
estimated 5 million new HIV infections occurred in 2003 alone (176).
While effective antiretroviral therapies are available, high drug costs
and weaknesses in medical infrastructure are obstacles to widespread
implementation (177, 178). Development of an efficacious HIV vaccine
will take many more years (179, 180). These constraints emphasize the
urgent need to address underlying social and structural determinants of
HIV/AIDS through sound policies and programs.
This work was supported by grant DA16527 from the National Institute
on Drug Abuse.
The authors thank Dr. David Vlahov of the New York Academy of
Medicine, Center for Urban Epidemiologic Studies for many helpful
comments and valuable insights.
APPENDIX TABLE 1. MeSH* keywords used to search databases for
published literature on the social epidemiology of HIV*/AIDS*
||Community networks; social
||Effects of neighborhoods
||Poverty areas; small-area
analysis; residential mobility; residence characteristics;
||Sex distribution; population
dynamics; transients and migrants
||Legislation, drug; legislation;
||Poverty; public policy; health
policy; health care reform; social welfare
||Structural violence and
||Attitude of health personnel;
prejudice; stereotyping; fear
|War, humanitarian crisis,
|Sex offenses; war crimes;
* MeSH, Medical Subject Headings (National Library of Medicine,
Bethesda, Maryland); HIV, human immunodeficiency virus; AIDS, acquired
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